Barbara Mitchell: Prevention of future deaths report
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Date of report: 12/05/2023
Ref: 2023-0153
Deceased name: Barbara Mitchell
Coroner name: Peter Straker
Coroner Area: North London
Category: Care Home Health related deaths
This report is being sent to: Bluebird Care (Kent)
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: Bluebird Care (Brent) 107 Kenton Road Harrow Middlesex HA3 0AN | |
| 1 | CORONER I am Peter Straker, Assistant coroner, for the coroner area of Northern District of Greater London |
| 2 | CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 |
| 3 | INVESTIGATION and INQUEST On the 13th July 2022 I opened an investigation touching the death of Barbara Mitchell , aged 94 years old. I opened and heard an inquest on the 7th December 2022. The conclusion of the inquest was “ Barbara Mitchell died as the result of an accident ”, the medical case of death was 1a Pneumonia, 1b Fracture of Sternum and under paragraph 2 Atrial Fibrillation. |
| 4 | CIRCUMSTANCES OF THE DEATH On the 9th July 2022 Barbara Mitchell died at Northwick Park Hospital having fallen at home despite being assisted at the time by a carer. |
| 5 | CORONER’S CONCERNS The MATTERS OF CONCERN are as follows. 1. Consideration of specialist training of staff in connection with the moving and handling of individuals, especially after a fall. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Friday the Seventh of July 2023 I, the assistant 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. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; The Family I am also 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 |
| 9 | 12-5-2023 |