Tina Murray
PFD Report
All Responded
Ref: 2020-0296
All 1 response received
· Deadline: 18 Feb 2021
Coroner's Concerns (AI summary)
Plastic bags, which posed a risk to the deceased, appear to have been accessible within Belgravia Care Home.
View full coroner's concerns
posed to Tina could not be guarded against. CORONER’S CONCERNS (1) Tina Murray posed a risk to herself, and specifically in relation to plastic bags, yet plastic bags appear to have been accessible within the home; (2) Belgravia Care Home looks after residents who may not be detained but who do suffer from mental health conditions, dementia, learning disabilities and it is
Responses
Action Taken
Belgravia Care Home removed plastic bags from resident bedrooms, safely disposed of shopping bags, locked away all other bags, and implemented robust risk assessments for residents at risk of suicidal tendencies. (AI summary)
Belgravia Care Home removed plastic bags from resident bedrooms, safely disposed of shopping bags, locked away all other bags, and implemented robust risk assessments for residents at risk of suicidal tendencies. (AI summary)
View full response
Dear Alan Anthony Wilson, am writing in a response to the regulation 28 that was sent to us in regards to Tina Murray' s death: In section 5 it points out concerns in Belgravia care home and how there is a risk that another death may occur at the home. Here are the safety measures and risk assessments that we have now into place_ Plastic bags in the home have now been removed them from all residents' bedrooms Residents that have been to the shops have had the removed, cut up and disposed of safely when coming back into the home All bags are locked away in the kitchen and cleaning cupboard which only management and senior carers have keys for access Staff will only have possession of plastic bags on their persons to use for continence products when doing personal care on residents and will be disposed of safely and taken to a locked outside commercial bin. All bags that have been used in the home will be immediately removed and put into the outside commercial locked bin: Individual robust risk assessments have been into place with the residents at risk of suicidal tendencies The time table for this action is immediate and has already been into place: Vouurs Cincerel Registered Manager Belgravia Care Home Proprietors Margaret and Martin Gregory 406 North Promenade Blackpool Lancashire FYI 2LB T 01253 595567 . F 01253 593578 E: belgraviacare@googlemail.com W: wwwbelgravia-care co.uk put bags put put
Sent To
- Belgravia Care Home Ltd
Response Status
Linked responses
1 of 1
56-Day Deadline
18 Feb 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
The death of Tina Murray on 8th January 2020 was reported to me and I opened an investigation, which concluded by way of an inquest held on 13th November 2020.
I determined that the medical cause of Tina’s death was 1 a Suffocation.
In box 3 of the Record of Inquest I recorded as follows: “Tina Murray had previously been diagnosed with paranoid schizophrenia and had had a history of self-harming behaviour. She resided in a care facility. Her presentation had been stable for a number of months. After being spoken to by staff during the morning of 8th January 2020 when no significant concerns were raised, Tina had a shower at around 11 am and remained in her room until approximately 11.50 am when she was found by care staff to be lay on her back on her bed and unresponsive. Tina had a white plastic bag which she had located in the care home secured over her head. Staff members immediately removed the bag and attempted cardio-pulmonary resuscitation. Paramedics were called and they transferred Tina to hospital where she was pronounced deceased at 13:38 hours. A subsequent post mortem examination confirmed that Tina died due to suffocation. The risk that Tina may seek to harm herself by gaining access to a plastic bag with the intention of voluntarily suffocating herself in order to end her life had not been fully recognized.”
The conclusion of the Coroner was that Tina Murray died due to Suicide.
I determined that the medical cause of Tina’s death was 1 a Suffocation.
In box 3 of the Record of Inquest I recorded as follows: “Tina Murray had previously been diagnosed with paranoid schizophrenia and had had a history of self-harming behaviour. She resided in a care facility. Her presentation had been stable for a number of months. After being spoken to by staff during the morning of 8th January 2020 when no significant concerns were raised, Tina had a shower at around 11 am and remained in her room until approximately 11.50 am when she was found by care staff to be lay on her back on her bed and unresponsive. Tina had a white plastic bag which she had located in the care home secured over her head. Staff members immediately removed the bag and attempted cardio-pulmonary resuscitation. Paramedics were called and they transferred Tina to hospital where she was pronounced deceased at 13:38 hours. A subsequent post mortem examination confirmed that Tina died due to suffocation. The risk that Tina may seek to harm herself by gaining access to a plastic bag with the intention of voluntarily suffocating herself in order to end her life had not been fully recognized.”
The conclusion of the Coroner was that Tina Murray died due to Suicide.
Circumstances of the Death
• Tina Murray was not a detained patient although she did reside within a care home reported to specialise in caring for clients with mental health conditions, elderly clients, clients who suffer with dementia, and learning disabilities. She was able to move around within the home and not confined to her room.
• In around June 2019, care staff witnessed Tina to be in possession of a plastic bag and to infer that she may use the bag to harm herself. Staff were concerned about this, and indeed it was established at the inquest that care staff were reminded about this concern over subsequent months. However, I found that Tina had been able to access a plastic bag from within the care home. Evidence was received on the basis that the bag used by Tina had most likely been obtained from inside one of the bins located in the rooms of other residents.
• It appeared to me that should a resident be intent on locating a plastic bag from within the home they would be able to do so and in Tina’s case with fatal consequences.
• Care staff were in my view placed in an impossible situation whereby on the one had they were being reminded that Tina gaining access to a plastic bag may be a concern but given that plastic bags were accessible within the building the risk posed to Tina could not be guarded against.
• In around June 2019, care staff witnessed Tina to be in possession of a plastic bag and to infer that she may use the bag to harm herself. Staff were concerned about this, and indeed it was established at the inquest that care staff were reminded about this concern over subsequent months. However, I found that Tina had been able to access a plastic bag from within the care home. Evidence was received on the basis that the bag used by Tina had most likely been obtained from inside one of the bins located in the rooms of other residents.
• It appeared to me that should a resident be intent on locating a plastic bag from within the home they would be able to do so and in Tina’s case with fatal consequences.
• Care staff were in my view placed in an impossible situation whereby on the one had they were being reminded that Tina gaining access to a plastic bag may be a concern but given that plastic bags were accessible within the building the risk posed to Tina could not be guarded against.
Copies Sent To
Lancashire & South Cumbria NHS Foundation Trust
Head of Adult Services, Blackpool Council
Care Quality Commission and to the LOCAL SAFEGUARDING BOARD (where the deceased was under 18)]
Inquest Conclusion
“Tina Murray had previously been diagnosed with paranoid schizophrenia and had had a history of self-harming behaviour. She resided in a care facility. Her presentation had been stable for a number of months. After being spoken to by staff during the morning of 8th January 2020 when no significant concerns were raised, Tina had a shower at around 11 am and remained in her room until approximately 11.50 am when she was found by care staff to be lay on her back on her bed and unresponsive. Tina had a white plastic bag which she had located in the care home secured over her head. Staff members immediately removed the bag and attempted cardio-pulmonary resuscitation. Paramedics were called and they transferred Tina to hospital where she was pronounced deceased at 13:38 hours. A subsequent post mortem examination confirmed that Tina died due to suffocation. The risk that Tina may seek to harm herself by gaining access to a plastic bag with the intention of voluntarily suffocating herself in order to end her life had not been fully recognized.”
The conclusion of the Coroner was that Tina Murray died due to Suicide.
The conclusion of the Coroner was that Tina Murray died due to Suicide.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.