On 29 April 2014 held and concluded an inquest (and investigation) into the death of Stanley Bere, aged 89 years old. The formal conclusion was that Stanley Bere, died on 4th June 2012 from congestive cardiac failure and bronchopneumonia; He had been immobile for some time following an assisted fall on 31st October 2011_ some 8 months earlier; in which he suffered a fractured ankle This fractured ankle together with the subsequent infection contributed to his death

Mr Bere had been a resident of the Villa Adastra nursing home since December 2009. He had during that time suffered a number of falls. On 31st October 2011 he had another fall; An incident report was completed where it was noted that he had suffered no injuries: The fall was not recorded at the time on the home's Cardex system: Mr Bere had in fact sustained a serious injury in the fall to his ankle. It then appeared that there were many missed opportunities by the staff at the home to spot these injuries: The family raised concerns on a number of occasions but it was not until 8"h November 2011 that action was taken and the true extent of Mr Bere's injury was discovered. His ankle had been fractured in two places which was required to be pinned in the Hospital_ After this procedure he returned back to the Care Home. A few weeks later the District nurse realised that one of the implanted screws was visible and the area was infected Again this was not picked up by the Care Home_ Mr Bere was readmitted to hospital where the screws were removed and the infection was treated. As a result of the ongoing infection all the metalwork had to be removed and this took place on 23rd May 2012. Sadly Mr Bere did not recover from this medical intervention he slowly deteriorated and died on 4th June 2012

In my opinion action should be taken to prevent future deaths and believe you ANDIOR your organisation has the power to take such action: and