Frederick Bevan
PFD Report
Historic (No Identified Response)
Ref: 2017-0060
No published response · Over 2 years old
Sent To
Response Status
Responses
0 of 1
56-Day Deadline
4 May 2017
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
was satisfied that Mr. Bevan'$ fall was witnessed by a carer] However, two paramedics who attended in response to the 999 call following the fall both gained the clear understanding that the fall was not witnessed; described that there were 4 or 5 members of staff present and the scene appears to have been somewhat chaotic The likely explanation for the paramedics misunderstanding is that a clear hand-over of the history of the incident was not provided by the witness_ but rather the nurses who has responded to the emergency call 'took over' . This was accepted as a potential explanation by the home manager Judy Williams, who informed me that the policy is that the lead nurse should give the incident history to the paramedics: my concern is that if the history is not provided by the witness (regardless of whether they are a carer or a nurse} there is a risk that the correct history will not be given to emergency services which in some cases could have a detrimental effect on treatment: and they
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 07/10/2016 commenced an investigation into the death of Frederick Bevan: The investigation concluded at the end of an inquest on Ist March 2017. The conclusion of the inquest was Accidental Death;
Circumstances of the Death
Mr Bevan passed away on 4/10/16 at Bromford Lane Care Centre, 28 Fairholme Lane; Washwood Heath, Birmingham a5 a result ofa head injury following a fall at the home on 22/9/16. Mr Bevan had been a resident of the Home since June 2014 and was subject to a Deprivation of Liberty Safeguarding Order due to his dementia: His health had deteriorated in the summer of 2016 with a number of falls recorded by the Home; On 22/9/16 he suffered another fall which was witnessed by a staff member at the Home: Paramedics attended the Home promptly Mr Bevan was admitted to Heartlands Hospital quickly. Following medical assessments it was concluded that no treatment or procedure would be beneficial to him. The decision was taken to return Mr Bevan to Bromford Lane to ensure his remaining days were as comfortable as possible He passed away shortly afterwards at the Home: Based on information from the Deceased's treating clinicians the medical cause of death was determined to be: 1(a) SUBARACHNOID HAEMORRHAGE 1(b) FALL 1(c) DEMENTIA
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.