Olive Nugent · Prevention of Future Deaths report

On 18/12/2014 I commenced an investigation into the death of Olive Nugent, 92 years old, dob 14/6/1922. The investigation concluded at the end of the inquest on 30th March 2015. The medical cause of death was established:

1a. Multiple Contusions Intracerebral Haemorrhage and diffuse Axonal Injury
1b. Head Injury (consistent with a fall)
II. Cerebrovascular Disease

The conclusion of the inquest was accidental death.

Olive Nugent lived independently with a care package including carer visits 4 times daily. She was provided with a falls detector device designed to automatically activate in the event of a fall. The device also had a facility for summoning help when required. Wardens were provided with guidance requiring response to device activation within 45 minutes.

On the 16th December 2014 Mrs Nugent fell down stairs at her home address. Her device activated at 8.58am. No attendance by a warden occurred until 11.25am. Mrs Nugent had sustained an un-survivable brain injury that led to her death.

(1) Mrs Nugent lay critically injured in her home for 2 hours and 27 minutes without assistance or access to medical treatment.
(2) Her falls activator device had activated automatically indicating that she had fallen.
(3) Her inability to respond verbally to call handlers via the device was a crucial factor in the decision not to prioritise her case.
(4) Priority was given to clients whose devices had activated in some cases at a time later than Mrs Nugent's but who had been able to verbally respond to call handlers via their devices.
(5) The prioritising of response to device activation is entirely subjective and heavily dependent upon (a) staffing levels and (b) the personal practices of individual team leaders.
(6) On 16th December 2014 there were insufficient staff to meet the demand for assistance. This contributed to the delayed response to Mrs Nugent's needs.
(7) A review of the Guidance to be adopted when responding to device activation was undertaken following Mrs Nugent's death.
(8) The Policy Document entitled "Mobile Response Time Targets, Prioritising Mobile Response and Escalation Process", however, reaffirms that prioritisation of response remains a subjective process. A proposed escalation process in the event of demand exceeding the capacity of available staff is dependent upon other agencies whose availability is not guaranteed or the subject of any Memorandum of Understanding.
(9) The provision of Falls Detection Devices is intended to ensure timely aid and assistance including medical treatment of injuries if required to vulnerable persons in the event of a fall.
(10)Further deaths could potentially occur in the future; particularly in cases of persons injured and unable to respond verbally to call handlers.
(11)Review of the Guidance and Policy Document and staffing levels is necessary to reduce this risk.