June Phillips
PFD Report
All Responded
Ref: 2025-0112
All 1 response received
· Deadline: 25 Apr 2025
Coroner's Concerns (AI summary)
Inaccurate care home records, failure to update falls risk assessments, and an inadequate post-falls investigation indicate a failure to learn from incidents and properly monitor patient deterioration.
View full coroner's concerns
1. The care home records were inaccurate and did not correctly reflect the deterioration in Mrs Phillips condition after the fall. There is a concern that this creates a risk of further deaths.
2. The risk assessment for prevention of falls was not updated when it should have been after her fall on 07/04/23 and when her condition deteriorated. There is a concern that this create a risk of further deaths as risk assessments are not up to date.
3. The post falls investigation did not adequately investigate the circumstances of the fall. There is a concern that this creates a risk of future deaths as lessons are not learnt from incidents.
2. The risk assessment for prevention of falls was not updated when it should have been after her fall on 07/04/23 and when her condition deteriorated. There is a concern that this create a risk of further deaths as risk assessments are not up to date.
3. The post falls investigation did not adequately investigate the circumstances of the fall. There is a concern that this creates a risk of future deaths as lessons are not learnt from incidents.
Responses
Action Taken
The care home has implemented a root cause analysis tool, uses body maps and photos for injuries, calls 999 in specific fall scenarios, implemented weekly GP ward rounds with detailed summaries, requires professional documentation on care plans, provided staff supervision and meetings on accurate reporting, updated the head injury policy, reports falls to safeguarding and CQC, refers residents with multiple falls to falls clinic, provides refresher first aid and manual handling training, implemented a documentation lead for oversight, and the manager has joined support groups. (AI summary)
The care home has implemented a root cause analysis tool, uses body maps and photos for injuries, calls 999 in specific fall scenarios, implemented weekly GP ward rounds with detailed summaries, requires professional documentation on care plans, provided staff supervision and meetings on accurate reporting, updated the head injury policy, reports falls to safeguarding and CQC, refers residents with multiple falls to falls clinic, provides refresher first aid and manual handling training, implemented a documentation lead for oversight, and the manager has joined support groups. (AI summary)
View full response
Friday 25th April 2025 Response for June Phillips
1.The documentation following a resident having a fall in the home is a8 follows the falls risk assessment (screening for tools part one and part two) are updated within 24 hours this is then followed through and documented within the care records. A root analysis tool along with an incident investigation form has now been implemented:
2. Body maps are in situ for resident who have sustained injuries and are updated daily, and photographs are taken of the wounds/injuries as evidence and are attached to the individual care plans:
3. Where the resident has a falland sustains an injury a a care is put in place The accident form is completed at the time ofthe fall and family notified: In the event of the resident sustaining an injury and, on a blood thinner 999 is called and documented: It is also the case following a fall and no apparent injury is identified 999 is also called when the resident is prescribed blood thinning medication:
4. GP's on weekly ward round from Northbrook Surgery have now implemented for good practice a detailed summary of their findings and outcomes for each resident and forward this information by email to the Care Home following the ward round. This Information is transferred onto each residents individual personalised care plan. This information is clear and transparent to all and avoids misunderstandings.
5. Professional i.e. social workers, best interest assessors are asked to document their findings directly on to the individuals personalised care plan: This again avoids miscommunication and clear and transparent understanding of the outcome
6. Each staff member within the care home has received a supervision. It is recorded and discussed within the supervision the importance of reporting and recording in an accurate and timely manner: All supervisions as of February 2025 and before this time reflects this discussion
7.Staff meetings have been held following June Phillips fall where it has been discussed the importance of documenting and reporting accurately and timely: A Staff meeting took place as of 11th March 2025 to inform the staff ofthe Coroners Court hearing regarding June Phillips and to discuss the importance of completing an accurate assessment of each accident and incident and also reacting promptly and in accordance to policy and updated guidance
8. Following the fall of June Phillips, we updated our policy regarding residents who sustain a head injury and are on a blood thinner medication 999 is called, but as plan
lessons learnt a resident on a blood thinner medication who falls regardless of a apparent injury 999 is now called for good practice. 9_ Residents who fall regardless of been on a blood thinner medication and have no apparent or visual injuries 111 is called for advice.
10. Falls are reported to safeguarding and followed by a CQC notification:
11.A resident who sustains two or more falls is referred to the fall's clinic and 3 falls within a 3-month period regardless of any injury are referred to safeguarding and a notification to CQC.
12. All staff are receiving refresher first aid training along with manual handling training: As of March 2025,all staff are receiving their refresher first aid training this is ongoing: Also, refresher Manual handling training:
13. The manager has joined a managers support group on social media which has proved to be very informative. The manager is also attending registered managers forums which again as proved very empowering:
14. We have implemented a lead of documentation who is responsible for checking and over seeing i.e. falls and risk assessments All accidents are audited monthly and responded to accordingly and in a timely manner: Care Home Manager
1.The documentation following a resident having a fall in the home is a8 follows the falls risk assessment (screening for tools part one and part two) are updated within 24 hours this is then followed through and documented within the care records. A root analysis tool along with an incident investigation form has now been implemented:
2. Body maps are in situ for resident who have sustained injuries and are updated daily, and photographs are taken of the wounds/injuries as evidence and are attached to the individual care plans:
3. Where the resident has a falland sustains an injury a a care is put in place The accident form is completed at the time ofthe fall and family notified: In the event of the resident sustaining an injury and, on a blood thinner 999 is called and documented: It is also the case following a fall and no apparent injury is identified 999 is also called when the resident is prescribed blood thinning medication:
4. GP's on weekly ward round from Northbrook Surgery have now implemented for good practice a detailed summary of their findings and outcomes for each resident and forward this information by email to the Care Home following the ward round. This Information is transferred onto each residents individual personalised care plan. This information is clear and transparent to all and avoids misunderstandings.
5. Professional i.e. social workers, best interest assessors are asked to document their findings directly on to the individuals personalised care plan: This again avoids miscommunication and clear and transparent understanding of the outcome
6. Each staff member within the care home has received a supervision. It is recorded and discussed within the supervision the importance of reporting and recording in an accurate and timely manner: All supervisions as of February 2025 and before this time reflects this discussion
7.Staff meetings have been held following June Phillips fall where it has been discussed the importance of documenting and reporting accurately and timely: A Staff meeting took place as of 11th March 2025 to inform the staff ofthe Coroners Court hearing regarding June Phillips and to discuss the importance of completing an accurate assessment of each accident and incident and also reacting promptly and in accordance to policy and updated guidance
8. Following the fall of June Phillips, we updated our policy regarding residents who sustain a head injury and are on a blood thinner medication 999 is called, but as plan
lessons learnt a resident on a blood thinner medication who falls regardless of a apparent injury 999 is now called for good practice. 9_ Residents who fall regardless of been on a blood thinner medication and have no apparent or visual injuries 111 is called for advice.
10. Falls are reported to safeguarding and followed by a CQC notification:
11.A resident who sustains two or more falls is referred to the fall's clinic and 3 falls within a 3-month period regardless of any injury are referred to safeguarding and a notification to CQC.
12. All staff are receiving refresher first aid training along with manual handling training: As of March 2025,all staff are receiving their refresher first aid training this is ongoing: Also, refresher Manual handling training:
13. The manager has joined a managers support group on social media which has proved to be very informative. The manager is also attending registered managers forums which again as proved very empowering:
14. We have implemented a lead of documentation who is responsible for checking and over seeing i.e. falls and risk assessments All accidents are audited monthly and responded to accordingly and in a timely manner: Care Home Manager
Sent To
- Willow Grange Care Home
Response Status
Linked responses
1 of 1
56-Day Deadline
25 Apr 2025
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
Report Sections
Investigation and Inquest
On 18 May 2023 I commenced an investigation into the death of June PHILLIPS. The investigation concluded at the end of the inquest. The conclusion of the inquest was; accident
Circumstances of the Death
Mrs Phillips resided in a care home as she suffered from Alzheimer's dementia and she took clopidogrel an antiplatelet medication to reduce the risk of clots. She required help with activities of daily living but remained mobile and would walk around the care home often at a fast pace. She was assessed as at high risk of falls and had several falls due to her constant walking. At 23.05 on 07/04/23 she fell forwards in the hallway causing an injury to her forehead and back. She was assessed and not thought to have any significant injury. 111 was called who advised further monitoring. The following day she presented as normal however from 09/04/23 her condition changed, and she appeared more sleepy and her mobility declined meaning she required more assistance. On 12/04/23 she was assessed by a GP as part of the weekly ward round who noted the fall and an injury to her right eye which was now very bruised but found no abnormalities or changes so advised further monitoring. On 13/04/23 she was noted to be struggling to walk and required a wheelchair and her mobility continued to deteriorate. After concerns were raised by her husband, she was reviewed again on 17/04/23 by a GP. The GP was not advised of any deterioration in her presentation and found no abnormal neurological signs but suspected she may have suffered a concussion from the fall. The plan was for her to be seen on the next weekly ward round, and she was given eye drops for an eye infection. She was not added to the list for the weekly ward round on 19/04/23. Mrs Phillips continued to deteriorate and require assistance and on 22/04/23 she was noted to be very sleepy. By 24/04/23 she was noted to be very unwell and struggling to walk and eat and drink independently and after review by a GP she was admitted to Birmingham Heartlands Hospital where a CT scan confirmed a large right sided traumatic subdural haemorrhage which was treated conservatively until her death on 30/04/23. It is likely she suffered a head injury when she fell on 07/04/23 and that clopidogrel caused the initial injury to worsen over time but it is not possible to say whether earlier admission to hospital would have impacted on the outcome. Based on information from the Deceased’s treating clinicians the medical cause of death was determined to be: 1a Traumatic Subdural Hemorrhage 1b
1c 1d II
1c 1d II
Copies Sent To
West Midlands Police
Solihull Metropolitan Borough Council
Medical Examiner, ICS, NHS England, CQC
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.