UK Inquiry Tracker

Joseph Tarnowski

PFD Report All Responded Ref: 2017-0247

Date of Report 24 August 2017

Coroner Chris Morris

Coroner Area Manchester (South)

Response Deadline est. 26 November 2017

Care Home Health related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 26 Nov 2017

Coroner's Concerns (AI summary)

A resident was unable to effectively use a call-bell due to potential unawareness of its portability or mobility limitations, highlighting a lack of consideration for alternative wearable alarm systems.

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In evidence at the inquest; it was confirmed that Mr Tarnoswki summoned assistance by shouting out (0 staff rather than by using his call-bell: It became apparent during the course of the hearing that Mr Tarnowski may not have been aware that his call-bell was wireless , and as such could be moved around his room. Additionally, the evidence revealed that even had Mr Tarnowski been aware that his call-bell was portable, he may not have been able to move it due to his reliance on a mobility aid_ At the time of the inquest, consideration had not been given to introducing call bells which are worn by residents of the fashion that are apparently in use in some other similar residential care setting_

Responses

Hillbrook Grange

Action Taken
Following the inquest, Hillbrook Grange Residential Care Home immediately provided residents with call bells to be worn around their necks. (AI summary)

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Dear Mr; Morris RE: Joseph TARNOWSKI In light of your recent Regulation 28 Report, you identified that we at Hillbrook Grange Residential Care Home could do more in respect of preventing future deaths You gave rise to concern that there is a potential risk that future deaths will occur unless immediate action is taken. am happy to say that from this verdict and report we have taken prompt and responsive action by way of providing residents with call bells that are to be worn around their necks. This was immediately actioned following the registered manager'$ participation into the inquest. Consequently, the board of directors approved this recommendation and purchased the call bells without delay and the system was implemented within the week. Ours service users are now fully equipped with their mobile call bells and we that we have dramatically reduced thc risk of serious impediments that result from a resident who may fall_ We are greatly appreciative of the recommendations you have provided to US in your report. belicve this has made thc environment for the residents at Hillbrook Grange & safe place: We the managers; board of directors and all the staff feel confident in consistently working hard to continuously make our home the best it can possibly be hope the improvements We have undertaken succeeds to the entireness You required for the recommendations to Hillbrook Residential Care Home Thank you. Kind regards Nsuk C1 Home Administrator Hillbrook Grange Residential Care Home; registered In England & Wales (no 07125607) Registered charity no: 1146488 hope Grange

Sent To

Hillbrook Grange Residential Care Home

Response Status

Linked responses 1 of 1

56-Day Deadline 26 Nov 2017

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 25th April 2017_ Alison Mutch OBE, Senior Coroner for Manchester South, opened an inquest into the death of Joseph Tarnowski who was aged 96 when he died at Stepping Hill Hospital, Stockport on 1Oth April 2017 . The investigation concluded at the of the inquest which heard on 4th August 2017 The conclusion of the inquest was that Mr Tarnowski died as a consequence of injuries sustained in a fall at Hillbrook Grange Residential Care home At the end of the inquest; recorded a conclusion of Accident: The medical cause of death was 1a) Bronchopneumonia and acute heart failure 1b) Immobility Ic) Fall, fractured humerus

Circumstances of the Death

Mr Tarnowski essentially enjoyed good heallh in his younger As years progressed, he developed some serious and debilitating health problems including deteriorating eyesight with wet macular degeneration. He also experienced a number of falls whilst living in his own home and as such, family members encouraged him to move to a residential care setting: Following an initial period living at a home in Bolton, Mr Tarnowski moved to Hillbrook Grange in April 2016. Mr Tarnowski settled into the home well, and essentially appeared to be in good health, although he did develop a number of chest infections_ Mr Tarnowski walked independently with the help of a walking aid, and remained wholly independent in respect of most activities of 'living: At all material times, Mr Tarnowski retained capacity to make decisions about the support and assistance he wished to accept or refuse at any given time_ On 7th April 2017_ Mr Tarnowski fell whilst getting changed in his bedroom: He was unable t0 get himself up, and called out to staff who came to assist him. Mr Tarnowski was (aken to Stepping Hill Hospital, Stockport; by ambulance where a displaced fracture of the neck of the left humerus was diagnosed Mr Tarnowski was treated conservatively for this injury and admitted to hospital On 9th April, Mr Tarnowski's condition deteriorated dramatically, and he sadly died the following day: Care end

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