Pauline BRUMFITT · Prevention of Future Deaths report

On 20 April 2020 I commenced an investigation into the death of Pauline BRUMFITT, 91. The investigation concluded at the end of the inquest on 25 March 2021. The conclusion of the inquest was

I a Intracranial bleed

I b

I c

II Secondary to Fall

Pauline BRUMFITT sadly died on 15th April 2020 at John Joseph Powel Nursing Home Merseyside.
Pauline had been cared for in another care home where she had an unwitnessed fall on 29th February 2020.
Pauline was found on the floor having fallen at about 15.25 hrs. The family who had visited earlier report leaving at about 14.45.
Pauline was taken to hospital where she was diagnosed with an intracranial bleed.
Upon her discharge from hospital Pauline went to a different nursing home, which is where she sadly passed away as stated.
The Care Home where Pauline fell did not undertake a falls risk assessment for Pauline as they should have done.
There was no falls mat or falls alarm in situ at the care home at the time of her third and final fall or at all.

There was no falls prevention plan in place as there should have been and there was no referral for advice from the falls team at the Local Authority.
Pauline had suffered from two previous falls at the same Nursing Home and the fall (3rd), leading to the admission to hospital (and the subsequent diagnosis of an intracranial bleed) caused or contributed to the death of Pauline Brumfitt.

[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The policies and procedures in existence at the care home pertaining to falls risk assessment and prevention were not applied to Pauline Brumfitt (as stated above) as they should have been.
(2) Pauline fell on 3 occasions and the opportunities to assess Pauline’s risks and take appropriate action to prevent further falls were not taken as they should have been.
(3) The matter was (given in evidence) not reported to the regulatory bodies and again as given in evidence an investigation had not been commenced at the time of the inquest and staff supervision/discussion re falls prevention had only been commenced in Feb/March 2021, appropriate timely action could have helped (and could still help) to prevent future deaths in similar circumstances where dependent elderly residents are at risk of falling and suffering serious injury/death as a consequence.