Margaret O’Brien

PFD Report Historic (No Identified Response)
Date of Report 11 December 2015
Coroner Chinyere Inyama
Coroner Area London (West)
Response Deadline ✓ from report 5 February 2016
Coroner's Concerns (AI summary)
Staff lacked specific, prescribed training on how to properly conduct and record observations of residents.
View full coroner's concerns
There appeared to be an absence of specific, prescribed training of staff on how to carry out and record observations of residents_
Sent To
  • CARE UK
Response Status
Linked responses 0 of 1
56-Day Deadline 5 Feb 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 22nd March 2014 commenced an investigation into the death of Margaret OBrien age 65_ The investigation concluded at the end of the inquest on 30"h September 2015 The conclusion of the inquest was that Ms OBrien died from natural causes_
Circumstances of the Death
The deceased was discovered unresponsive in her bed at the care home where she resided in having shown signs of a cold the previous evening:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action.
Related Inquiry Recommendations

Public inquiry recommendations addressing similar themes

Care homes in scope for new regulatory regime
Fuller Inquiry
Care home safety and capacity

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