Wilhelmina Isobel Newton
PFD Report
All Responded
Ref: 2013-0283
All 1 response received
· Deadline: 26 Dec 2013
Coroner's Concerns (AI summary)
The care home lacked clear written protocols and guidance for staff on responding to head injuries in elderly residents, particularly those on anti-clotting medication.
View full coroner's concerns
On the evidence heard it appeared there was no clear written plan , protocol or guidance to the staff as to how they should respond to a potential head injury to an elderly resident, particularly one receiving medication which had the potential to affect the blood’s clotting ability: the absence of such guidance may apply to other residential homes operated by the Council
Responses
Action Taken
Cumbria County Council has reviewed the issues regarding procedures to be followed when a resident sustains or is suspected of sustaining a head injury and updated their policy, embedding it throughout the organisation and with independent providers. (AI summary)
Cumbria County Council has reviewed the issues regarding procedures to be followed when a resident sustains or is suspected of sustaining a head injury and updated their policy, embedding it throughout the organisation and with independent providers. (AI summary)
View full response
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Sent To
- Cumbria County Council Carlisle
- Cumbria County Council Carlisle
Response Status
Linked responses
1 of 2
56-Day Deadline
26 Dec 2013
All responses received
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 13th May 2013 I commenced an investigation into the death of Wilhelmina Isobel Newton, 98. The investigation concluded at the end of the inquest on 21st October 2013. The conclusion of the inquest was Medical cause of death 1a) Subdural Haematoma b) Fall Conclusion: On the 14th May 2013 in her room at Grisedale Croft Residential Home the deceased was put into bed at about 03.00 hrs. At 04.30 hrs she shouted and was found to be lying on the floor next to her bed. Later that morning she was found to be unrousable and was admitted to Cumberland Infirmary where she died on 15th May 2013. She died as the result of an Accident.
Circumstances of the Death
The deceased had a history of falls both before and after becoming a resident at Grisedale Croft. She had fallen out of bed and banged her head at 04.30 hours. She was not attended by a nurse until 09.45 hours shortly after which an ambulance was summoned. She was prescribed regular aspirin. S:\Statutory functions\Rule 43 and PFD\Post April 2013\Newton 2013-0283.doc
Action Should Be Taken
by way of a review of the procedures to be followed when a resident is suspected of sustaining a head injury particularly when that person is prescribed medication which affects the blood’s ability to clot.
Copies Sent To
Chairman, The Adult Safeguarding Board Public Protection Unit, Cumbria Constabulary
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.