Margaret Richardson
PFD Report
Historic (No Identified Response)
Ref: 2016-wp25380
Coroner's Concerns (AI summary)
A robust, comprehensive Action Plan with timescales needs to be put in place, following the findings of the Serious Incident Investigation and the evidence heard during the inquest.
View full coroner's concerns
it is my statutory duty to report to you.
(1) a robust, comprehensive Action Plan with timescales' needs to be put in place, following the findings of the Serious Incident Investigation and the evidence heard during the inquest.
(1) a robust, comprehensive Action Plan with timescales' needs to be put in place, following the findings of the Serious Incident Investigation and the evidence heard during the inquest.
Sent To
- North Essex Mental Health Partnership Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
16 Oct 2016
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 [26 January 2016] I commenced an investigation into the death of Margaret Ann Richardson. The investigation concluded at the end of the inquest on 17 August 2016.
The conclusion of the inquest was a Narrative conclusion:- On 5 September 2015, the deceased was admitted to Kitwood ward St Margaret's Hospital Epping. She suffered a number of falls and she died on 25 January 2016 in Princess Alexandra Hospital Harlow. At least the last fall may have contributed to her death. There were failings in the implementation of the North Essex Mental Health Partnership Trust's Prevention and Management of Falls Policy in Kitwood ward.
The cause of death was 1a) Bilateral pneumonia 11) subdural haematomata, ischaemic heart disease
The conclusion of the inquest was a Narrative conclusion:- On 5 September 2015, the deceased was admitted to Kitwood ward St Margaret's Hospital Epping. She suffered a number of falls and she died on 25 January 2016 in Princess Alexandra Hospital Harlow. At least the last fall may have contributed to her death. There were failings in the implementation of the North Essex Mental Health Partnership Trust's Prevention and Management of Falls Policy in Kitwood ward.
The cause of death was 1a) Bilateral pneumonia 11) subdural haematomata, ischaemic heart disease
Circumstances of the Death
The deceased suffered at least 5 falls while a patient in Kitwood Ward St Margaret's Hospital Epping and she died in Princess Alexandra Hospital Harlow after the last fall.
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
GMMH local structured risk assessment responsibility
Southport Inquiry
Conflicting mental health care plans
Prevent discharge of hospitalised children with concerns until home is safe
Laming Inquiry
Care and discharge planning
Require consultant or paediatrician permission for discharging children with protection concerns.
Laming Inquiry
Care and discharge planning
Require documented future care plan for discharging children with protection concerns.
Laming Inquiry
Care and discharge planning
Ensure identified GP for children with deliberate harm concerns discharged from hospital.
Laming Inquiry
Care and discharge planning
Require effective communication among healthcare professionals to avoid conflicting patient advice
Bristol Heart Inquiry
Conflicting mental health care plans
Establish comprehensive counselling and support services as integral to patient care
Bristol Heart Inquiry
Care and discharge planning
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.