Gordon Penistan
PFD Report
All Responded
Ref: 2017-0313
All 1 response received
· Deadline: 27 Dec 2017
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
27 Dec 2017
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
_ Adults' services in other Iocal authority areas are to experience similar cases and could benefit from the lessons learnt from the review in this case and the actions_taken_by_Hampshire Coroner Oftice, Castle Hill, The Castle; Winchester; S023 SUL Tel 01962-667884 Fax 0[962-667893 being and likely
County Council to address the shortcomings highlighted by the death The Association would be ina position to share this information with other Adult Services_
County Council to address the shortcomings highlighted by the death The Association would be ina position to share this information with other Adult Services_
Responses
Response received
View full response
Dear Mr Short,
In response to your letter and regulation 28 report to prevent future deaths we have circulated the attached briefing to all 153 local authorities with responsibility for adult social care. This was done via our news bulletin which is sent out every Tuesday afternoon. The following was sent as part of the news bulletin on Tuesday 31 October:
Confidential Briefing We would like to draw your attention to a situation where a Coroner has issued a Regulation 28 Report (Prevention of Future Deaths). The circumstances and learning have been shared by the DASS concerned. Please see this confidential briefing for further information.
We trust this satisfies the requirement to share the lessons learnt and please let us know if any further action needs to be taken.
In response to your letter and regulation 28 report to prevent future deaths we have circulated the attached briefing to all 153 local authorities with responsibility for adult social care. This was done via our news bulletin which is sent out every Tuesday afternoon. The following was sent as part of the news bulletin on Tuesday 31 October:
Confidential Briefing We would like to draw your attention to a situation where a Coroner has issued a Regulation 28 Report (Prevention of Future Deaths). The circumstances and learning have been shared by the DASS concerned. Please see this confidential briefing for further information.
We trust this satisfies the requirement to share the lessons learnt and please let us know if any further action needs to be taken.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you; the Association of Directors of Adult Social Services have the power to take such action.
Report Sections
Investigation and Inquest
On 5 June 2017 commenced an investigation into the death of Gordon Penistan aged, 84_ The investigation concluded at the end of the inquest on 26 October 2017. The conclusion of the inquest was Accidental death. determined that at about 14.00 on 24 May 2017 Gordon Penistan was unsettled by a loud noise at Otterbourne Grange Residential Home in Otterbourne and went from the dining room to a staircase in the home and then sustained an unwitnessed fall as a result of which he suffered an injury to his head. Mr Penistan suffered from dementia and was disorientated;, having just moved to the home and he was treated with anticoagulation therapy. He died as a result of Ia Subdural Haematoma 1b Trauma to the Head
Circumstances of the Death
Gordon Penistan was diagnosed with posterior cortical atrophy which affected his visual perception as well as vascular dementia_ He lacked mental capacity and in February 2017 he moved to a residential home capable of supporting dementia sufferers where he settled after some initial issues of aggression: The cost of the home was depleting his funds and so his family applied for local authority funding which was agreed, but Hampshire Adults' Health and Care insisted that Mr Penistan should be moved to a less expensive home that could meet his needs_ From April 201-responsibility for placement had passed to a newly formed brokerage team who lacked experience in dealing with such referrals There was no "best interests meeting and a lack of adequate communication with the case worker and with the family. No consideration was given to renegotiating terms with the existing care home or to the effects of a move on Mr Penistan in light of his condition: In consequence of this death Hampshire County Council instigated a Critical Incident Review as a result of which it has made improvements to the brokerage process by introducing prior senior management authorisation and further training of the brokerage team. In addition it is in the process of issuing guidance both for staff for families about moving from self funding to local authority funding:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.