Alan Massam · Prevention of Future Deaths report

On 24th October 2019, I commenced an investigation into the death of Alan Massam. The investigation concluded on the 15th March 2021 and the conclusion was one of accident. The medical cause of death was 1a Lower respiratory tract infection; 1b Multiple rib fractures; 1c Falls; II Acute on sub-acute subdural haematoma, advance dementia, frailty.

Alan Massam was a resident at Reinbeck Residential Home. As his dementia progressed, his behaviour changed significantly and his family were served with a notice that they needed to make alternative arrangements.
He moved to Lisburne Court, a dementia residential home. The preadmission process was not followed fully. Medication had not had any significant impact on his behaviour. Mental health services were involved in supporting the care home.
He had a series of falls and was taken to Stepping Hill Hospital on 13th October 2019, 10 days after arriving at Lisburne Court. A small bleed was identified.
He was discharged back to the Care Home without contact being made with the home. The home had not answered the telephone when calls were made. No observations were taken prior to discharge. No discharge notice was sent with him.
On 14th October, the GP prescribed antibiotics for a suspected chest infection. He refused to take them and refused fluids. His family were not communicated with effectively. He had a series of falls on 15th October.
On 16th October he was taken back to Stepping Hill Hospital. A further traumatic bleed to the brain was identified and also a number of recent rib fractures. He was treated with antibiotics and fluids but deteriorated rapidly and was placed on end of life care and died at Stepping Hill Hospital on 24th October 2019.

1. The inquest heard that the care of Mr Massam was complex due to his needs but there was no clear agreement or arrangement between agencies as to how to effectively share information in complex cases.in his case mental health services were involved as was the acute trust, GP and the care home but there was limited evidence of a joint approach to ensure his care was optimised. This included a limited understanding by those involved of when and how to use of s.9 assessments to reduce the risk to a vulnerable adult such as Mr Massam.
2. Mr Massam was discharged back to the care home by the acute trust. The inquest heard that the home would not have accepted him back if they had been spoken to as they did not feel they could meet his needs. The inquest heard that there is no national guidance/protocol about what an acute trust should do if attempts to contact a home are unsuccessful or about the obligation to ensure the home can accept him back in such circumstances as these.
3. The staff at the home were aware of the prescribing of medication including antibiotics. However when he refused them and fluids there was no defined escalation process which would ensure that the risk this presented was recognised and acted on.
4. Once the initial home could not manage Mr Massam and served a notice on the family there was a significant pressure to find another home that would accept him. Whilst the search was undertaken he remained in a home where staff felt they could no longer safely meet his care needs. The inquest heard that this search was exacerbated by a national shortage of suitable beds within the adult care sector for complex cases such as Mr Massam.