On 14th May 2012 I commenced an investigation into the death of Douglas Grey then aged 72 years. The investigation concluded at the end of the inquest on the 25th September 2013. I concluded the inquest with a narrative, the medical cause of death being right sided pneumonia due to an acute subdural haematoma.

1. The deceased had been in a residential home since 2008 and, as a result of pressure sores after discharge from hospital, was given an inflatable mattress which was placed on top of the original mattress on his bed.
2. There were no cot sides or other safety features used.
3. He suffered a fall from his bed on the day the inflatable mattress was installed. Staff removed the mattress as they were concerned over it ‘slipperiness’. He then suffered a second fall a few days later. The mattress was then advised to be removed by the district nurse.
4. A few days after the second of the falls he became unconscious and had to be transferred to hospital where he died, despite treatment, in the early hours of the 5th May 2012.

For recipient (1) it is clear a system to carefully monitor installation and performance of equipment recommended by district nursing teams should be set up. In addition, the operation of the system should be audited on a regular basis since potential consequences of absence of or poor operation of such systems are potentially so serious. For recipient (2) it is clear that the operation of the practice and procedures set down by written protocols need to be audited clearly and regularly.
7. You are under a duty to respond to this report within 56 days of the date of this report namely by 3rd December 2013. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.