Elsie Raper
PFD Report
Partially Responded
Ref: 2016-0090
2 of 3 responded · Over 2 years old
Response Status
Responses
2 of 3
56-Day Deadline
29 Apr 2016
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) That Elsie Raper; being a patient and subject to regular visits and examination by GP's and nurses, suffered a fracture to her left tibia and left tibula probably on 21" August 2015, which remained undiagnosed until the 25"h August 2015.
(2) During the period 215 _ August she was in extreme pain (3) The cause of death included multiple fractures:
(2) During the period 215 _ August she was in extreme pain (3) The cause of death included multiple fractures:
Responses
Response received
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Dear Sir Re: Elsie Raper Deceased Following the recent conclusion of the inquest into the death of Mrs Elsie Raper, we have received the regulation report to prevent further deaths The inquest highlighted the of the diagnosis of fractures sustained. The review in our clinical meetings of 5" February 2016and 12th April 2016, discussed this fact and outlined the following action points: A fall in an elderly frail person should prompt investigations. A minor trauma may result in a fracture: prompt referral via an ambulance for assessment (specifically an x-ray) should be initiated without delay: 2 The care plan needs to include any factors to prompt and support this action like history of dementia or osteoporosis: Regular review of contributing risks of falls needs to be assessed and reviewed regularly to implement right staffing/supervision level and safety equipment (eg Zimmer frames, walking aids, supporting staff;, wheelchairs etc) as well as medication reviews which may affect the level of alertness and mobility: We have discussed the issues with the staff at Grosvenor Park Care Home and trust that we can reduce the risk through the measures taken above:
Response received
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Dear Re: Mrs Elsie Raper Deceased Following the recent conclusion of the inquest into Raper's death, we have now received Investigation Report: The inquest highlighted a need for a response from us regarding details of actions taken since Mrs Raper's death: I can now confirm that the actions listed below have been initiated: 24 Hour Falls Observation Charts: allowing staff to monitor a residents condition more closely after a fall ad gives us documentary evidence to support ay concerns we have when contacting external healthcare professionals; may 2 A list of all residents with a confirmed diagnosis of Osteoporosis has been completed ad is held in the Home for review ad reference by the staff team. This allows the team to recognise which residents may have an increased susceptibility to fractures following a fall:
3. Residents Plans have been reviewed and rewritten to incorporate the details associated with a diagnosis of osteoporosis and increased risk of fracture;
4. Followirg a low impact fall for a resident with diagnosis of osteoporosis the home refers to the Community Matron for review due to the increased risk of fracture: We have discussed these actions with the GP ad extended Multidisciplinary Team who have agreed these actions and willingness to support the team;
3. Residents Plans have been reviewed and rewritten to incorporate the details associated with a diagnosis of osteoporosis and increased risk of fracture;
4. Followirg a low impact fall for a resident with diagnosis of osteoporosis the home refers to the Community Matron for review due to the increased risk of fracture: We have discussed these actions with the GP ad extended Multidisciplinary Team who have agreed these actions and willingness to support the team;
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power t0 take such action: YOuR RESPONSE are under a to respond to this report within 56 days of the date of this report, namely by April 2016_ 1, the Coroner, may extend the period: Your response must contain details of action taken or proposed to be taken, setting out the timetable for action_ Otherwise you must explain why no action is proposed.
Report Sections
Investigation and Inquest
On 3r September 2015 commenced an investigation into the death of Elsie Raper; The investigation concluded at the end of the inquest on 18 March 2016. The conclusion of the inquest was that Elsie Raper died from Ia. Multiple Bone Fractures (of left tibia, left fibula and Ieft femur) treated 1b. Multiple Falls including recent fall on 218 August 2015, Frailty of Old Age and Osteoporosis_ She suffered a fall on 10lh June 2015, resulting in a fractured tip of femur for which she was treated: The implications of osteoporosis were not appreciated: She suffered further falls when she was admitted to Darlington Memorial Hospital on 11 just 2015 and on 215 August 2015 when she suffered fractures of the left tibia and fibula which could have been; but were not diagnosed until 25th August 2015. She died at Grosvenor Park Care Home, Darlington on 26ih August 2015. The overall conclusion was accidental falls causing_ fractures
Circumstances of the Death
Elsie Raper was born on 6lh August 1921. She entered the Grosvenor House Care Home; Burnside Road, Darlington in January 2014. She had a diagnosis of osteoporosis from 2007 was self-mobilising: She had capacity. She suffered a fall on 10h June 2015. This resulted in a fractured tip of femur: She was treated for this. Osteoporosis is mentioned in her medical notes from the GP's surgery, Neasham Road, at this time. She was admitted to hospital and discharged back to Grosvenor House Care Home on 22md June 2015. She had a further fall on 11"h August; There was another fall on 21s' August; In her evidence the Care Manager accepted that there was insufficient attention given to the possibility of fractures arising in the light of Elsie's osteoporosis. Elsie received on most days attention including examination on 13"" August; 15" August, August, August and August 2015 from nurses from Darlington Out of Hours Service and Darlington District Nursing: She was examined by a GP from Neasham Road Surgery on 17lh August 2015 and 24th August 2015. She was examined by a Doctor from Bishop Auckland Urgent Care on 23r August 2015.It was on 24h August that she was referred to hospital. She was referred for X-Ray: It was the evidence of her daughter of Elsie Raper that it was she who insisted upon the X-Ray: The evidence of a GP from Neasham Road Surgery was that he accepted that there had been a delay in treating the fractures: The evidence from a Consultant in Emergency Medicine at Darlington Memorial Hospital was that the presentation of Elsie's leg on 25" August,_irrespective of the X-Ray results,made tor a likely diagnosis of fractures to the Auge She Home 17th 22n _ 24th
Elsie s family members stated that she had been in extensive pain after 21" August
Elsie s family members stated that she had been in extensive pain after 21" August
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.