Doris Taylor
PFD Report
Historic (No Identified Response)
Ref: 2014-0164
Coroner's Concerns (AI summary)
The coroner noted that staff training should include a full and clear understanding as to what constitutes a reportable incident and the managers should be aware of their duty to report such. The door-closers on all doors should be in a safe working condition.
View full coroner's concerns
_ Staff training should include a full and clear understanding as to what constitutes reportable incident and the managers should be aware of their duty to report such The door-closers on all doors in such an establishment should be in a safe working condition, and of such 'strength' as to be efficient in causing the door to close at the same time not so 'strong' as to make it dangerous as they close (as to knock over the person as happened to Mrs Taylor). due being yet
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:
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:
Sent To
- Borough Care Limited
Response Status
Linked responses
0 of 1
56-Day Deadline
5 Jun 2014
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 7th January 2014 commenced an investigation into the death of Doris Taylor dob 3rd October 1931. The investigation concluded on the 31st March 2014 and the conclusion was one of Accidental Death: The medical cause of death was 1a Pneumonia and multi organ failure 1b Fracture neck of femur (operated) and Il Meningioma, intracranial haemorrhage and hypertension:
Circumstances of the Death
On the 20"h November 2013 she was admitted to Marbury House Care Home to decreased mobility and pains in her back: She was assessed as at high risk of falling: During the course of her stay she suffered 3 separate falls. It would appear that the second of these falls was due to a defective door-closer which caused the door to close knocking Mrs Taylor over. The senior member of staff who attended the inquest to give evidence was unaware of the need to report such incidents to the Health and Safety Executive and further stated that she_was not trained as t0 which matters are reportable under RIDDOR
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.