Sheila Ross
PFD Report
Historic (No Identified Response)
Ref: 2018-0081
No published response · Over 2 years old
Sent To
Response Status
Responses
0 of 1
56-Day Deadline
11 Aug 2018
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
Coroners Concerns
In the circumstances Civic Centre; Burdon Road,Sunderland, SR2 7DN Tel 0191 5617843 Fax 0191 5537803 DX 60729 Sunderland WWW.sunderland.gov uklcoroner aged sepsis urinary it is statutory duty to report to you: (1) The falls risk assessment tool used by the Care Home staff appeared to be outdated, and the subsequent level of falls risk recorded by staff was not in keeping with the score generated by the assessment tool.
(2) The Care Home buzzer system only allowed one alert mechanism personal buzzer or sensor mat to be active at any one time, unless a resident could access the wall buzzer_ This can leave residents unable to summon timely assistance when needed: (3) There was poor communication from the Care Home with Sheila' s family members, which led them to lose confidence in the standard of care Sheila was receiving:
(2) The Care Home buzzer system only allowed one alert mechanism personal buzzer or sensor mat to be active at any one time, unless a resident could access the wall buzzer_ This can leave residents unable to summon timely assistance when needed: (3) There was poor communication from the Care Home with Sheila' s family members, which led them to lose confidence in the standard of care Sheila was receiving:
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 12th November 2017 Mrs Sheila Sullivan Ross (Sheila), 86 years, died at Sunderland Royal Hospital. The Inquest; as part of my Investigation, concluded on 14uh March 2018, when [ recorded a conclusion of Accident. The Cause of Death following Post-Mortem Examination was: Ia Pelvic Haematoma Ib Fracture Pubic Rami II Chronic Ischaemic Heart Disease
Circumstances of the Death
Sheila was admitted to Sunderland Royal Hospital on 10th November 2017 following an unwitnessed fall at the Hylton View Care Home_ It was initially thought that Sheila had not sustained any serious injury from her fall. However; after care staff had hoisted her into her chair, she began to complain of pain, and an ambulance was called. An X-ray examination showed stable bilateral pubic rami fractures, which were suitable for supportive treatment only via rest and analgesia: Sheila was found to have a urinary tract infection and was treated for urinary via insertion of catheter; intravenous fluids, oxygen and antibiotics. pelvic ultrasound scan was ordered to assess her bladder issue. Sheila sadly deteriorated and passed away on 12th November 2017.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.