Arthur Johnson
PFD Report
All Responded
Ref: 2021-0003
All 1 response received
· Deadline: 2 Mar 2021
Coroner's Concerns (AI summary)
Care home's "Post-Falls" policy lacked clarity on when to call emergency services for possible head injuries, and staff training on recognising intracranial injury was insufficient.
View full coroner's concerns
The MATTERS OF CONCERNS are as follows: Oakridge House Residential Home is staffed by non-medically trained personnel. The “Post-Falls” process/policy direct that 999/111 should be called when a head injury is suspected. The evidence at inquest indicated that where a head injury was considered a possibility 999/111 was not called. My concern is that the present process does not give adequate direction, provide sufficient clarity nor distinguish between “possible” and “suspected” head injury. It is not clear when 999/111 should be called. Further, I have concerns in relation to the training provided to assist Residential Home staff in the recognition of intracranial injury.
Responses
Action Taken
Hampshire County Council updated its "falls protocol" in line with current NICE guidance, clarifying that staff should contact 999 or 111. Additionally, staff will now participate in a standalone learning module on falls management, including head injury risk. (AI summary)
Hampshire County Council updated its "falls protocol" in line with current NICE guidance, clarifying that staff should contact 999 or 111. Additionally, staff will now participate in a standalone learning module on falls management, including head injury risk. (AI summary)
View full response
Dear Mr Pegg,
Report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 dated 5 January 2021 in connection with the investigation into the death of Arthur Edward JOHNSON.
Further to the above report of the inquest concluding “accident” and medical cause of intracerebral haemorrhage, I have noted your concerns relating to the response by staff at Oakridge House Residential Home and perceived shortcomings in the management of falls and suspected head injury.
I have now had the opportunity to follow up the matter further and am able to provide additional information that may not have been previously presented during your investigation, for which I apologise.
I understand that when you requested the documentation for Mr Johnson’s inquest, you received only part of the current “falls protocol”. As a result of your recommendations the entire protocol has been reviewed and updated in line with current NICE guidance. This clearly directs staff to contact 999 or 111. The revised protocol is attached and I trust addresses the concern relating to the clarity of practice guidance.
Regarding staff training, previously staff were trained in how to respond to head injury events during our “Emergency Aid” course. Following your comments, this has been reviewed. Although staff working in a residential setting are not clinically trained, they will now be required to participate in a standalone learning module designed specifically to focus on falls management issues, including risk of head injury. This will compliment other practice guidance for example risk assessment and risk management plans for mobile elderly people in a communal living setting.
Jason Pegg Area Coroner for Hampshire, Portsmouth and Southampton Castle Hill, The Castle, Winchester, SO23 8UL Enq ui ri es to
My r ef er en ce
Dir ect li n e
Yo u r r ef er en ce
Da te 23 February 2021 E-ma il
Adults’ Health and Care 3 r d Floor, Elizabeth II Court West Sussex Street Winchester Hampshire SO23 8UQ Telephone Telephone
I apologise again that you were not provided with all the relevant information at the time of your initial request. I trust this letter will reassure you that the matter has been taken seriously and as a result revised guidance and training arrangements established.
Report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 dated 5 January 2021 in connection with the investigation into the death of Arthur Edward JOHNSON.
Further to the above report of the inquest concluding “accident” and medical cause of intracerebral haemorrhage, I have noted your concerns relating to the response by staff at Oakridge House Residential Home and perceived shortcomings in the management of falls and suspected head injury.
I have now had the opportunity to follow up the matter further and am able to provide additional information that may not have been previously presented during your investigation, for which I apologise.
I understand that when you requested the documentation for Mr Johnson’s inquest, you received only part of the current “falls protocol”. As a result of your recommendations the entire protocol has been reviewed and updated in line with current NICE guidance. This clearly directs staff to contact 999 or 111. The revised protocol is attached and I trust addresses the concern relating to the clarity of practice guidance.
Regarding staff training, previously staff were trained in how to respond to head injury events during our “Emergency Aid” course. Following your comments, this has been reviewed. Although staff working in a residential setting are not clinically trained, they will now be required to participate in a standalone learning module designed specifically to focus on falls management issues, including risk of head injury. This will compliment other practice guidance for example risk assessment and risk management plans for mobile elderly people in a communal living setting.
Jason Pegg Area Coroner for Hampshire, Portsmouth and Southampton Castle Hill, The Castle, Winchester, SO23 8UL Enq ui ri es to
My r ef er en ce
Dir ect li n e
Yo u r r ef er en ce
Da te 23 February 2021 E-ma il
Adults’ Health and Care 3 r d Floor, Elizabeth II Court West Sussex Street Winchester Hampshire SO23 8UQ Telephone Telephone
I apologise again that you were not provided with all the relevant information at the time of your initial request. I trust this letter will reassure you that the matter has been taken seriously and as a result revised guidance and training arrangements established.
Sent To
- Hampshire County Council and Oakridge House Residential Home
Response Status
Linked responses
1 of 1
56-Day Deadline
2 Mar 2021
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 21st April 2020 I commenced an investigation into the death of Arthur Edward JOHNSON aged
85. The investigation concluded at the end of the inquest on 5th January 2021. The conclusion of the inquest was: Accident The Medical Cause of Death was: I a Intracerebral Haemorrhage I b Fall I c II Spontaneous intracranial haemorrhage, Hypertension, Alzheimer's Disease
85. The investigation concluded at the end of the inquest on 5th January 2021. The conclusion of the inquest was: Accident The Medical Cause of Death was: I a Intracerebral Haemorrhage I b Fall I c II Spontaneous intracranial haemorrhage, Hypertension, Alzheimer's Disease
Circumstances of the Death
The deceased died on 20th April 2020 at the Royal Hampshire County Hospital, Winchester, Hampshire. The deceased suffered an unwitnessed fall on 17th April 2020 at Oakridge House Residential Home in consequence of which the deceased suffered a head injury and intracerebral haemorrhage. The deceased had also suffered a spontaneous intracranial haemorrhage which contributed to the death of the deceased.
Action Should Be Taken
7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 02 March 2021. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (Spouse). I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. Jason PEGG Area Coroner for Hampshire, Portsmouth and Southampton Dated: 05 January 2021
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.