Anoush Summers: Prevention of future deaths report

Other related deaths

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Date of report: 06/06/2024

Ref: 2024-0310

Deceased name: Anoush Summers

Coroner name: Edwin Buckett

Coroner Area: Inner North London

Category: Other related deaths

This report is being sent to: London Borough Hackney | Supreme Care Services Limited

Regulation 28: Prevention of Future Deaths report
[REDACTED] Chief Executive London Borough Hackney Town Hall Mare Street London E8 1EA   [REDACTED] Director of Supreme Care Services Limited 9 Crown Parade Morden Surrey SM4 5DA
I am: Edwin Buckett Assistant Coroner Inner North London Poplar Coroner’s Court 127 Poplar High Street London E14 0AE
I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29.
On the 22nd January 2024 Assistant Coroner Sarah Bourke began an investigation into the death of Anoush Summers who died aged 77, on the 14th January 2024 at Homerton University Hospital, Homerton Row, London, E9.  

The investigation concluded at the end of the inquest on 6th June 2024 conducted by myself, Assistant Coroner Edwin Buckett.

I made a determination at inquest that the deceased died as a result of hypothermia which resulted from a fall at home following a long lie.
The narrative conclusion was as follows:
The deceased was a frail lady who was prone to falls. She lived at home, alone, with carers who visited her twice a day. She had a wrist alarm.
The wrist alarm was reported as broken and not working on the 6.1.2024, but it was not repaired or replaced.
Sometime after 4.45pm on 11.1.2024, the deceased fell at home. She was found the next day on the 12.1.2024 at 9am, by a carer, wearing her wrist alarm and taken to hospital where she died on 14.1.2024 of hypothermia.
The absence of a working wrist alarm prevented her from being found sooner that she was and probably contributed to her death.
During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows.
Evidence was given that:
Although the wrist alarm had been reported as broken and not working on the 6.1.2024, this was not replaced or repaired by the company engaged by the local authority to provide this service before the deceased fell at home between 11-12.1.2024.
At the time the deceased fell, she was wearing her wrist alarm but could not use it to summon help because it did not work.

None of the carers who attended on the deceased after 6.1.2024 ensured that steps were taken to replace the wrist alarm or report the matter to the local authority.
The last carer who attended on the deceased before she died, on the 11.1.2024, was not aware that the wrist alarm did not work as she had not read the care notes. No clear instruction was given to care workers about the extent to which they would be expected to read the care notes relating to service users.
None of the carers had been given any training, instruction, or guidance on the testing of wrist alarms to ensure they worked properly when attending upon service users.
There was no clear system identified between the company providing carers and the local authority, as to the duties and responsibilities of each in the reporting of faults with wrist alarms.
I rely on all the above matters.
I am concerned that there is a risk of future deaths arising in circumstances when vulnerable people, who live at home and are reliant of wrist alarms which have been reported as not working, but have not yet been repaired, may unable to summon help.
In my opinion, action should be taken to prevent future deaths and I believe that you and/or your organisation have the power to take such action.
You are under a duty to respond to this report within 56 days of the date of this report, namely by 2nd August 2024. 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.
I have sent a copy of my report to the following.
HHJ Alexia Durran, the Chief Coroner of England & Wales
[REDACTED], the daughter of Anoush Summers.
I am under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.
Edwin Buckett