Olive Wilmott
PFD Report
Historic (No Identified Response)
Ref: 2016-0231
Coroner's Concerns (AI summary)
An alleged assault was not effectively investigated or safeguarded, and the care home failed to meet observation requirements due to insufficient night staff for residents' needs.
View full coroner's concerns
_ That there were references in the medical records to Miss Wilmott possibly having been pushed, but no or no effective investigation of circumstances was made at the time and no Safeguarding referral was made. That Miss Wilmott was assessed as requiring observation at 15 minute intervals, but there was no evidence that this had been in place and at the time of the event there were insufficient staff in place for her and other residents' needs (one staff member dedicated per floor of the dementia unit during the night shift) .
Sent To
- Ideal Care Home Ltd
Response Status
Linked responses
0 of 1
56-Day Deadline
16 Aug 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 21st March 2016 an investigation was begun into the death of Olive Wilmott; who died on 30th December 2015. The investigation concluded at the end of the Inquest on 20"h June 2016. The conclusion of the Inquest was that Olive Wilmott died as a result of the effects of a urine infection and severe Dementia, with a hip fracture which she suffered at Coppice Lodge Residential Care Home on 6th December 2015 contributory factor, and a Narrative Conclusion was recorded_
Circumstances of the Death
Miss Wilmott was found on the floor of a communal area of the Home, having fractured her hip. The exact cause of this event remains unknown:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe your organisation has the_power to take such action: being the
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.