UK Inquiry Tracker

Ruth Gregory

PFD Report All Responded Ref: 2019-0017

Date of Report 11 January 2019

Coroner Alison Mutch

Coroner Area Manchester (South)

Response Deadline est. 18 July 2019

Care Home Health related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 18 Jul 2019

Coroner's Concerns (AI summary)

Regular unsupervised communal areas in the care home led to resident injuries from falls, highlighting inadequate risk management and supervision arrangements.

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The inquest heard that Mrs Gregory's had required the knee replacement after being knocked over by another resident in the care home: The her inquest was told that residents were regularly left unsupervised in communal areas of the care home and that this meant similar incidents could reoccur leading to trauma and consequential death. There was no detail available at the inquest about how this risk was managed and arrangements to ensure supervision of communal areas. ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and | believe you have the power to take such action: YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by &h March 2019. !, 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. COPIES and PUBLICATION have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely MMrs Gregory's daughter, who may find it useful or of interest: Iam 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 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; Alison Mutch OBE HM Senior Coroner 11.01.2019 Kw may

Responses

Borough Care Local Authority / Fire Service

4 Feb 2019

Action Taken
Borough Care has increased staffing levels in their homes, including a deputy manager and senior carer on each shift, to reduce the time communal areas are left unattended. (AI summary)

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Dear Ms Mutch Thank you for your correspondence of the 11mh January following the death of Ruth Gregory: Following the Inquest, have taken on board your comments regarding the communal areas being left unattended: The fall happened In 2014 and at that time the staffing levels were considerably lower than they are today: This time last year January 2018 we increased the staffing levels In all our homes due to the dependency of the residents we are caring for: There are now 8 staff on shift 8am _ 8pm including a deputy manager and senior carer: Monday to Friday there is also a Manager and an administrator: Seven days per week there are also housekeeping staff and catering staff. At night there are now 4 slaff on duty including a senior carer; where there only used to be 3 staff: Whilst there may be occasions when the communal areas are unattended for short periods this has been significantly reduced by the increase in staffing levels. All residents have an individual risk assessment; and this would state if were unable t0 be left unattended. As the majority of residents who live In Reinbek have capacity they would be able to use the nurse call system to contact the staff if required any assistance During busy tlmes of the day or when care staff are assisting residents with personal care the deputy manager and the senior carer are around the communal areas administering medication or completing support plans. INVESTORS Baouch Coo Unilod b an Indutralcnd Fravicenl Soclaty Silver whciilobo _tolla: IN PEOPLE AntinanJon*t Kam Buaitau Putl, Kaaton Lne sortpon 504 MAS Raoelcrod Num3ai 277e8r they . they

hope that with the additional stafiing hours that have been put into place slnce the fall and the addition of a deputy manager on shift every you can be rest assured that the communal areas are safe for our residents: Please do not hesitate t0 contact me if yOu need any further inforation:

Sent To

Reinbek Care Home

Response Status

Linked responses 1 of 1

56-Day Deadline 18 Jul 2019

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 4th July 2018 | commenced an investigation into the death of Ruth Gregory: The investigation concluded on 7th January 2019 and the conclusion was one of Narrative: Died from natural causes contributed to by the recognised complications of an accidental fall. The medical cause of death was Ia) Aspiration Pneumonia; II) Infected Right Total Knee Replacement Ruth Gregory had significantly reduced mobility following a fall resulting in a total knee replacement: Subsequently she developed an infection in knee and was treated at Stepping Hill Hospital. She returned to Reinbeck Care Home where she began vomiting suggestive of an upper GI bleed. She was readmitted to Stepping Hill Hospital where she deteriorated due to aspiration pneumonia and died on Znd July 2018.