Charles Lawrence
PFD Report
All Responded
Ref: 2014-0342
All 1 response received
· Deadline: 19 Sep 2014
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
19 Sep 2014
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 lacks a critical protocol to ensure a doctor examines residents who experience multiple falls within a 24-hour period, indicating a gap in immediate medical assessment for recurrent fallers.
Responses
Response received
View full response
Dear Mr Horsley Re: Inquest Zth July 2014_Mr Charles Lawrence_Coroner' s Regulation 28 Report Further to vour Regulation Report towards Alexandra Rose Care Home am writing to you with the actions the Company are to take The home has devised a 'falls alert' notification that will be faxed to the residents doctors surgery should fall more than once over a 24 hour period. This has been agreed by the Drayton Medical Practice, although have not as vet received any further response from the two other surgeries that the home uses. In this case the home will call these surgeries direct should a second fall arise within that period. We currently have over 25 residents registered at Drayton Medical Practice which is a substantial amount so hope that you agree that this is the most important surgery to support us with this protocol: Further to this document; each resident now has this Protocol in their care plans under there mobility and falls risk assessments_ have enclosed a copy of the falls alert notification form, which / hope satisfies your requirements under note 5 of your report:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action:
Report Sections
Investigation and Inquest
On 30"h May 2013 commenced an investigation into the death of Charles Cecil Lawrence, aged 89 The investigation concluded at the end of the inquest on 7th July 2014. The conclusion of the inquest was Mr Lawrence died due to an Accident: The medical cause of this death was: la: Spinal Cord Compression Ib: Fractured Thoracic Vertebrae 2: Congestive Cardiac Failure and Pneumonia
Circumstances of the Death
On 2nd April 2013 Charles Cecil Lawrence fell in the residential home where he lived. He was visited by his GP who noted no apparent injury to Mr Lawrence. Mr Lawrence fell again later that but his GP was not recalled: By 1 April 2013 Mr Lawrence was in increasing distress and his condition deteriorated his GP admitted him to Queen Alexandra Hospital, Portsmouth, where he was diagnosed as having sustained an untreatable spinal injury: He died at Queen Alexandra Hospital on 23rd 2013 at 06.40 hours_
Similar PFD Reports
Reports sharing organisations, categories, or themes with this PFD
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Amend GLOS to allow claimants oral submissions at panel hearings
Post Office Horizon Inquiry
Care risk assessment failures
Post Office to engage in negotiations during HSSA appeal period
Post Office Horizon Inquiry
Care risk assessment failures
Require multidimensional risk assessments throughout operations
Jermaine Baker Inquiry
Care risk assessment failures
Amend firearms authorisation forms for risk assessment and tipping points
Jermaine Baker Inquiry
Care risk assessment failures
Draw up maternity risk assessment protocol
Morecambe Bay Investigation
Care risk assessment failures
Require comprehensive child needs assessment before admission to care
Waterhouse Inquiry
Care risk assessment failures
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.