Keith Whetton
PFD Report
All Responded
Ref: 2019-0452
All 1 response received
· Deadline: 18 Feb 2020
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
18 Feb 2020
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns AI summary
The care home failed to seek prompt medical attention after a resident's fall and did not inform family members in a timely manner.
Responses
Response received
View full response
Dear Andrew Haigh am writing to vou in response of the letter vou sent to myself regarding Keith Graham Whetton (deceased)_ After reviewing the coroners report we have been through your concerns and we have already addressed the concerns that you have highlighted, to to prevent future deaths: Following the fall all staff have been supervised on the matter and have completed falls training: Trained staff are going to be commenced additional training via remit training group. | myself and the clinical lead have completed the course and believe it will be beneficial for other senior to complete_ have also reviewed the policy and procedure of falls within the home and spoken with the regional mangers regarding unwitnessed falls and the policy and procedure has now been updated and in place within the home: The policy is now more robust and has clear instructions on steps to be taken in the event of a fall: After my trend analysis and internal investigation have increased staffing levels to increase observation of residents and further support to the nursing team: This level of support has had a positive impact in reducing falls and improving patient safety: believe that actions taken have improved the service, especially around patient safety: feel we have all learned lessons regarding this matter and as a service we will continue to strive to improve the care we deliver to our clients and families. Ifthere is any further information you require please do not hesitate to ask:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action
Report Sections
Investigation and Inquest
On 23 October 2019 | commenced an investigation into the death of Keith Graham WHETTON: The investigation concluded at the end of the inquest: The conclusion of the inquest was An elderly man in declining health who fell in a care home: The cause of death was: 1a End Stage Dementia and frailty Fracture right neck of femur 3 . CIRCUMSTANCES OF THE DEATH Keith had an unwitnessed fall in his room at Hunters Lodge Care Facility on the 07.09.191 attended as part of his Monday morning visit to the care home on the 09.09.19. He then sent Keith to New Cross Hospital Wolverhampton on the 09.09.19, where he was found to have a fractured right hip. He was then operated on and had a hemiarthroplasty and remained in hospital, until he was discharged back to the Care home on the 27.09.19. Sadly he continued to deteriorate and died at the home on the 05.10.19 Staffordshire Place, Stafford, ST16 2LP Telephone: 01785 276126 or 276127 Email; sscor@staffordshire.gov.Uk Lodge
4CQRONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken: In the circumstances it is my statutory duty to report to you:
5. The MATTERS OF CONCERN are as follows_ You should already be aware of the concerns in this matter. Even if medical attention was not sought for Keith on 7th September it clearly should have been requested on 8th September: We hope that this has now been taken on board by your home: Additionally, family members felt that should have been informed earlier about Keith's fall and wonder if lessons have been learned here as well:
4CQRONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken: In the circumstances it is my statutory duty to report to you:
5. The MATTERS OF CONCERN are as follows_ You should already be aware of the concerns in this matter. Even if medical attention was not sought for Keith on 7th September it clearly should have been requested on 8th September: We hope that this has now been taken on board by your home: Additionally, family members felt that should have been informed earlier about Keith's fall and wonder if lessons have been learned here as well:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.