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.
The right person is often the quickest person
A concern I’ve had for a while is that the principles of “Right Care, Right Person” are being misapplied, and I’m not alone.
If you’re not familiar, this is the approach, adopted by most forces now, that the police are – to paraphrase – not necessarily the right people to respond when someone has mental health stuff going on. This is obviously a sensible approach, however, far too often I’m seeing cases where the cops should have been there. Police should attend when there is “a real and immediate risk” to a person’s life.
In May, the Coroner reported on the sad death in January this year of Sophie Cotton. Her mother and social worker were basically begging the police to attend and got the runaround to non-urgent services – even though there were huge red flags. In the end, the first people who got there were relatives who forced entry and found her dead.
In another case reported last month, just after midnight on 4th February 2024 a member of the public called police to report concerns about a man’s welfare. The caller was passed between the police and ambulance service, and gave up in frustration. No further was taken or efforts made to get back in touch. A couple of days later, Paul Alexander was reported missing and his body was discovered in the local marina on the 14th. CCTV showed he had entered the water later on the night the call to police had been made.
Providers of supported living particularly may well find themselves having to argue the case for police attendance as the most appropriate.
Care home concerns
I’m not entirely clear if there was meant to be a connection, but a care home’s record keeping after a fall was criticised when the Coroner reported on their resident’s death in hospital following a choking incident in the hospital.
Another home from the same brand was criticised in the report into the death of Ian Simpson, who died of sepsis after being found unresponsive one morning in December last year. As well as delaying in calling an ambulance, the Coroner was thoroughly unimpressed by the home’s records, with “significant concern about their adequacy and accuracy”.
Telecare and emergencies
Mr and Mrs Cleall, an elderly couple, died in a fire in their home in Croydon, despite Mrs Cleall pushing her pendant alarm. Communication was poor due to her being stuck in the living room away from the telecare box. the operator couldn’t hear the smoke alarm either and so dispatched the usual responders. On their arrival they immediately called the fire brigade but it was too late.
There were concerns about the Clealls’ assessment, but the fire brigade also made it clear that they think telecare services should by default be recommended to include the enhanced package option. This includes a smoke detector which, when triggered, sends an urgent signal to the call operator without the need for the client to operate the pendant button.
Certainly, it seems sensible this should be the default for emollient users, smokers or anyone else at particular risk. Domiciliary providers should ensure they are aware of exactly what telecare support their clients have and escalate any concerns.
Death by walking stick
This month, the Coroner reported on the death of Dorothy Gamby, who was 100 years old when she inadvertently stood on the wide foot of her walking stick, leading to it coming apart and her falling. Unfortunately, the fall led to a fractured hip and wrist, and she deteriorated following pneumonia after surgery.
These kinds of wider ferrules which add claws or feet to a walking stick are common, and all providers should be aware of the risk and ensure it is a consideration in safely supporting people to stand and walk when they use such sticks.
Some topics appear every month and are too frequent and depressing to write about; we know them well enough – concerns such as lack of mental health provision, ambulance/ A&E delays and medical failures caused lack of communication between systems and teams.
If you need any advice, please do not hesitate to get in touch.
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