Sylvia Gibson
PFD Report
All Responded
Ref: 2022-0342
All 1 response received
· Deadline: 22 Dec 2022
Coroner's Concerns (AI summary)
Critical information about a resident's fall was not conveyed by care home staff to a visiting doctor, highlighting a lack of robust systems for sharing important patient details with healthcare professionals.
View full coroner's concerns
Although staff at Lambton House Care Home were aware of her fall in the early hours of 17th August, and this information was handed over to other staff, the same information was not conveyed to the doctor who visited Sylvia (being “not her usual self”) at around lunchtime that day. It appears that no systems were in place to ensure that important information is conveyed to healthcare professionals. Evidence does not suggest that this communications failure contributed to Sylvia’s death.
Responses
Action Taken
Following a fall incident, Lambton House implemented immediate actions: mandatory full documentation of falls, visual checks by senior staff, recording of observations (O2 sats, pulse, BP, temp, resps), contacting appropriate medical personnel, and following documented advice. Senior staff received supervision on communication and documentation. (AI summary)
Following a fall incident, Lambton House implemented immediate actions: mandatory full documentation of falls, visual checks by senior staff, recording of observations (O2 sats, pulse, BP, temp, resps), contacting appropriate medical personnel, and following documented advice. Senior staff received supervision on communication and documentation. (AI summary)
View full response
Subject: [EXTERNAL]:Notification of Inq Conclusion for PIPs GIBSON S 18082022 Date: 03 November 2022 16:22:20 CAUTION: This email originated from outside of the organization. Do not click links or open attachments unless you recognize the sender and know the content is safe.
In response to your report in relation to S Gibson, dated the 27/10/2022, the following actions have been implemented with immediate effect Any witnessed or unwitnessed fall must be fully documented. The service user is to be visually checked by the senior care manager on duty. All observations are to be completed and recorded (O2 sats, Pulse, BP, Temp, Resps). The appropriate medical persons are to be contacted at the time and informed of witnessed/unwitnessed fall. (999, 111, Recovery at Home, GP.) All observations will be passed over to the relevant clinician for advice. The advice given will be documented and followed. The above actions must be followed in the event of any fall. All senior members of staff will receive a supervision on the importance of communication and documentation. They have also received a copy of the above actions. Regards
Registered Manager Lambton House New Lambton Fencehouses Houghton le Spring DH4 6DE
In response to your report in relation to S Gibson, dated the 27/10/2022, the following actions have been implemented with immediate effect Any witnessed or unwitnessed fall must be fully documented. The service user is to be visually checked by the senior care manager on duty. All observations are to be completed and recorded (O2 sats, Pulse, BP, Temp, Resps). The appropriate medical persons are to be contacted at the time and informed of witnessed/unwitnessed fall. (999, 111, Recovery at Home, GP.) All observations will be passed over to the relevant clinician for advice. The advice given will be documented and followed. The above actions must be followed in the event of any fall. All senior members of staff will receive a supervision on the importance of communication and documentation. They have also received a copy of the above actions. Regards
Registered Manager Lambton House New Lambton Fencehouses Houghton le Spring DH4 6DE
Sent To
- Lambton House LTD
Response Status
Linked responses
1 of 1
56-Day Deadline
22 Dec 2022
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 Second September 2022 I commenced an investigation into the death of Sylvia GIBSON, aged 96. The investigation concluded at the end of the inquest on 27th October 2022. I found that the deceased died as a result of natural causes to which accidental injuries contributed.
Circumstances of the Death
Sylvia sustained an unwitnessed fall in the early hours of 17th August 2022 thereby sustaining injuries. These injuries were not reported to the attending medical practitioner.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.