The Coroners and Justice Act 2009 provides coroners with the duty to make reports to a person, organisation, local authority or government department or agency where the coroner believes that action should be taken to prevent future deaths.
Many of these are related to social care, and each month I review the most recent and share any learning and reminders that I think will be of value to providers.
Falls
In September 2024, Anthony Wood died in St. Helier Hospital following a fall from his bed. His death shows the importance of doing things properly: he needed staff for personal care, due to his known high risk of falls. On the morning of his fall, the HCA who arrived first began the tasks while awaiting their colleague. Unfortunately, they lowered the bed rail as part of the prep work and Mr. Wood rolled out of bed. He was frail, and as there were no crash mats the blow to his head from the floor was fatal.
In another hospital fall, Sarah Hill’s death in November 2024 raised concerns about lack of risk assessments, bed rails, call bells and lack of supervision.
Esther Byrne, aged 92, died in December 2024 following a fall the previous month. In her case the coroner raised concerns about the hospital staff’s quality of information and communication with her health & welfare PoA, as well as the discharge information given to her care home.
GOV.UK: Bed rails: management and safe use
NICE NG249: Falls: assessment and prevention in older people and in people 50 and over at higher risk
Early sepsis detection is vital
This month, the coroner in East London reported on the death of Norma Campbell, whose symptoms of sepsis were missed in a busy A&E.
Care staff must ensure they are familiar with the signs and may have to advocate for people they care for.
UK Sepsis Trust: What is Sepsis?
Skin integrity
In Nottingham, the coroner was concerned that a pressure ulcer had contributed to the death of Maureen Powell, following poor care in a nursing home.
There is NO EXCUSE for poor pressure area care. This critical area much be closely monitored – both people’s skin and the records about it!
Skills for Care: Pressure Ulcers
Bogus hospital discharges
Discharges from hospital where the person wasn’t truly ready have been an issue in care for many years, and the current financial and NHS pressures are not helping.
I started calling them “bogus” a long time ago because I realised that most of these people were clearly not ready for discharge and/or they did not have the required services or equipment in place to enable them to be so.
David Bendell‘s death in July 2024, reported this month by the Suffolk coroner, is such a case. According to the report:
David’s family described how the ambulance team that brought David home considered taking him straight back to hospital as they did not think he would be able to manage at his home. In addition, one of the first physiotherapists to see David reportedly said ‘this is not going to work’ to family members on seeing David in his accommodation.
Homecare providers particularly will inevitably face this sort of situation and should be prepared.
As well as the above, there are also the common issues of lack of mental health provision and ambulance delays.
If you need any advice, please do not hesitate to get in touch.
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