Allan Shepard

PFD Report Historic (No Identified Response) Ref: 2018-0313
Date of Report 23 October 2018
Coroner Angharad Davies
Response Deadline ✓ from report 19 December 2018
Coroner's Concerns (AI summary)
Response times for falls were missed due to inadequate staffing with one-person responder units, and crucial updated patient information was not passed to the third-party call centre.
View full coroner's concerns
_ (1) Wide Care Alarm Service's own guidance requires where there has been a fall a response should be provided within 30 minutes. During the time period when Mr Shepard was waiting for a response, there were two units available, However; one of the units was made up of only one person: The two person unit was engaged answering other calls in the 30 minutes following Mr Shepherd's alert one person responder unit was available to attend calls during this 30 minutes period but could attend a fall to provide assistance. Although the ambulance was contacted their response time was given as 4 hours_ This 50% reduction in responders available to answer calls may risk further deaths when a person has suffered a fall. Therefore, Wide Care Service is invited to consider its staffing levels and systems for providing cover. It is also invited to reconsider its policy regarding one person responder units when the injured person is already attended by someone else who may be able to assist; (2) The information that had been provided to the call handling centre by Wide Care Alarms about Mr Shepard and his family situation had been updated since 2015. On this occasion Mr Shepard was assisted by his son who himself had a visual impairment. Mr Shepard junior was struggling to see the difficulty his father was in. This is important information that may allow operators to prioritise calls andlor provide more complete information to the emergency services to allow them to accurately prioritise the call, Updated information about Mr Shepard was available to City Wide Care Alarms but had not been passed on to their third party call centre contractors. It would be helpful if the information could be updated when there is a significant change and Wide Care Alarms is invited to consider how this can be done
Sent To
  • City Wide Alarms
  • Sheffield City Council
Response Status
Linked responses 0 of 2
56-Day Deadline 19 Dec 2018
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 14 February 2018 commenced an investigation into the death of Allan Herbert Shepard age 89. The investigation concluded at the end of the inquest on 5 October 2018. The conclusion of the inquest was that Mr Shepard' death was an accident and he died from positional asphyxia.
Circumstances of the Death
Mr Shepard was 89 years of age and vulnerable due to a number of health conditions_ His family had arranged for to be supported by City Wide Care Alarms Service , which is a service that Mr Shepard paid for. He had this service installed at his home to enable him to have immediate access to an operator who could provide a Responder service to assist Mr Shepard if he ran into difficulties On 8 February 2018 Mr Shepard fell at home whilst assisted out of his wheelchair, in a hoist; by his son: His son alerted the City Wide Care Alarm call centre to seek assistance Mr Shepard's call was logged for the Responders to attend. The stated response time for Responders is 30 minutes. However, there are usually only two responder teams on duty to service the whole of Sheffield, Usually these crews are made up of two people so that can respond to all situations including falls. On 8 February 2018 this occasion one crew was made Up of only one person which meant that were unable to be sent to respond to falls. Therefore, the operator allocated Mr Shepard's fall to the ambulance service which had a 4 hour wait time Whilst Mr Shepard was waiting, trapped in his hoist, for assistance he ran into difficulties with his breathing: His son communicated this to the operator and Mr Shephard's call was given a higher priority by the ambulance service. But by the time the ambulance crew attended at Mr Shepherd"s address he had already lost consciousness due to him being they they positional asphyxiation and died Iater that day in hospital. His death could have been prevented.
Action Should Be Taken
In my opinion action should be taken t0 prevent future deaths and believe you or your organisation have the power to take such action
Related Inquiry Recommendations

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Hepatologist Oversight and Fibroscan Access
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Delayed Recognition of Deterioration
Specialist Hepatology Centre Access
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Uncertainty About Fibrosis
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Fibroscan for Liver Imaging
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Consultant Hepatologist Access
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Commissioning Hepatology Services
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Pre-1996 Transfusion Testing
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Incomplete GP Patient Data Transfer
New Patient Registration Screening
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Incomplete GP Patient Data Transfer
Quarterly assessment of staffing levels against population needs
Brook House Inquiry
Care home staffing levels
Ensure senior manager presence and accessibility to staff
Brook House Inquiry
Care home staffing levels

Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.