Eldine Lashley
PFD Report
Historic (No Identified Response)
Ref: 2021-0308
No published response · Over 2 years old
Sent To
Response Status
Responses
0 of 1
56-Day Deadline
11 Nov 2021
Over 2 years old — no identified published response
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
1. Mrs Lashley's mobility care plan was not updated in response to developments in her care needs - specifically the need to observe her more frequently than once per hour.
2. Progress notes created by nursing and care staff did not accurately reflect the frequency of checks carried out on Mrs Lashley.
2. Progress notes created by nursing and care staff did not accurately reflect the frequency of checks carried out on Mrs Lashley.
Report Sections
Investigation and Inquest
On 18th April 2021 I commenced an investigation into the death of Eldine Loretta Lashley aged 82 years. The investigation concluded at the end of the inquest on 2nd September 2021 . The conclusion of the inquest was that Mrs Lashley died from:
1.a Subdural Haematoma; II. Advanced dementia, Type 2 diabetes mellitus, Chronic kidney disease, Hypertension A short form conclusion of accidental death was arrived at.
1.a Subdural Haematoma; II. Advanced dementia, Type 2 diabetes mellitus, Chronic kidney disease, Hypertension A short form conclusion of accidental death was arrived at.
Circumstances of the Death
5 7
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.