George Renshaw Brown
PFD Report
Historic (No Identified Response)
Ref: 2013-0230
Coroner's Concerns (AI summary)
A lack of efficient systems for reassessing and transferring care home residents with rapidly deteriorating conditions led to significant delays in moving a patient to more suitable accommodation.
View full coroner's concerns
The MATTERS OF CONCERN is as follows.
(1) There is clear evidence given that Mr Brown was placed, properly, at Mayfield Care Home and that Mayfield Care Home were looking after him within the capabilities of that type of establishment: It soon became apparent to the Manager of that Care that were unable to meet the needs of Mr Brown's advancing dementia and whilst she brought this to the attention of the appropriate authorities nonetheless it took several months to have him moved to a suitable alternative accommodation There seemed to be no or no proper and efficient system in place for a speedy re-assessment and transfer of patients whose condition is deteriorating_rapidly: To Home they
(1) There is clear evidence given that Mr Brown was placed, properly, at Mayfield Care Home and that Mayfield Care Home were looking after him within the capabilities of that type of establishment: It soon became apparent to the Manager of that Care that were unable to meet the needs of Mr Brown's advancing dementia and whilst she brought this to the attention of the appropriate authorities nonetheless it took several months to have him moved to a suitable alternative accommodation There seemed to be no or no proper and efficient system in place for a speedy re-assessment and transfer of patients whose condition is deteriorating_rapidly: To Home they
Sent To
- Care Quality Commission
- Manchester Clinical Commissioning Group
- Trafford Borough Council
Response Status
Linked responses
0 of 6
56-Day Deadline
24 Mar 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 March 2013 commenced an investigation into the death of George Renshaw Brown who was born on 13 January 1925 and the investigation concluded at the end of the Inquest on 30 August 2013. The conclusion of the Inquest was that the deceased died from 1a) Pneumonia due to 1b) Cervical spine fracture and under Part Il: Acute on chronic bilateral cerebral haematoma and dementia and the conclusion reached by me was that of Accidental Death:
Circumstances of the Death
On Sunday 17 February 2013 the deceased, who was a resident at Mayfield Care Home, left the premises via a fire door and fell down some concrete steps, He fractured his cervical spine and thereafter developed pneumonia leading to his death:
Action Should Be Taken
In my opinion action should be taken t0 prevent future deaths and believe you and your organisation have the power t0 take such action.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.