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Investigation and inquest
On 27th January 2017 I commenced an investigation into the death of Ivy Mitchell. The investigation concluded on the 11th July 2017 and the conclusion was one of Narrative: Died as a result of natural causes with a contribution being made by injuries sustained in an accidental fall. The medical cause of death was 1a Left sided bronchopneumonia; II Left subcapital fracture
Circumstances of the death
Ivy Mitchell was a resident at a care home. She had a history of falls. On 29th December 2016 she had a fall in her room. She appeared to mobilise afterwards. On the evening of 29th December she said she felt unwell. On 30th December following a discussion with her GP, a taxi was called and she went to Tameside General Hospital. A subcapital fracture and pneumonia was diagnosed. She was initially too unwell for surgery. She was operated on, on 7th January 2017. She dislocated her hip on 19th January 2017 but was not suitable for further surgery. She began to show further signs of infection on 25th January 2017. She deteriorated and died on 26th January 2017.
Coroner’s concerns
1. The documentation relating to the falls risk was inaccurate. It did not refer to previous falls and did not reflect her mobility;
2. There was a lack of understanding amongst the care home staff of risk assessments; reviews and the required process following a fall. This included documenting observations after a fall.
3. Processes relating to escalation following a fall were not complied with; and
4. There was a lack of understanding of the trigger for a referral to the community nutrition team.
Information checked against the published report and official responses