On the 25 March 2021, I commenced an investigation into the death of Mrs Tripta Bhanote. The investigation concluded at the end of the inquest on 4 August 2021. The conclusion of the inquest was a short form conclusion of open conclusion:

The cause of death was:

1a Unascertained

i) Mrs Bhanote was 86 years old. She had a background medical history of dementia and diabetes. Mrs Bhanote had moved into Anson Court residential care home on 26th March 2020 for respite care due to family circumstances at the family home at that time. ii) The placement was secured by the Walsall Local authority social services department. iii) She initially had trouble settling into the new environment and needed further 1:1 care and change in medication (Risperidone). iv) The respite period was subsequently extended into May 2020. v) She was found on the floor of her bedroom on the 5 May and had sustained bruising to her face and shoulder. vi) On the 9 May she was again found on the floor at around 4.45am and no apparent injuries were found. She was placed back into bed by care staff. Later that morning at around 9am she was again found on the floor by care staff. vii) Her condition declined rapidly, and there was confusion amongst staff

[IL1: PROTECT] whether a “Do not attempt to resuscitate (DNAR)” order was in place. viii) She sadly passed away a short time later.

1. The care home owners may wish to consider reviewing their training and guidance on DNAR and escalation to emergency services.

2. The Hospital Trust may wish to consider reviewing their guidance and communication with care homes in relation to the role of the Enhanced care and quality team.