Christiana Dawson: Prevention of Future Deaths Report

Care Home Health related deaths

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Date of report: 16/10/2024 

Ref: 2024-0557 

Deceased name: Christiana Dawson

Coroners name: Tanyka Rawden

Coroners Area: South Yorkshire (West)

Category:  Care Home Health related deaths

This report is being sent to: Darnell Grange Nursing Home  

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

Darnell Grange Nursing Home
84 Poole Rd   
Darnall   
Sheffield   
S9 4JQ. 
1CORONER 

I am Tanyka Rawden, Senior Coroner for the Coroner’s area of South Yorkshire (West). 
2CORONER’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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3INVESTIGATION and INQUEST

On 24 June 2024 I commenced an investigation into the death of Christiana Betty Dawson, known as Betty, aged 94. The investigation concluded at the end of the  inquest on 10 October 2024. The conclusion of the inquest was a narrative  conclusion as follows: 

Christiana Betty Dawson fell at least ten times whilst a resident at Darnell Grange  Care Home in Sheffield. On 16 March 2024 she fell and was moved into her bed by  carers. Paramedics attended and identified a fractured left neck of femur. It cannot be said whether the fracture was caused by the fall or her being moved. 

She underwent surgery to repair the fracture on 18 March 2024 and died on 19 March 2024 at the Northern General Hospital in Sheffield as a result of the fracture and her frailty. 

Her falls risk assessments and care plans were reviewed after each fall, but no  changes were made. An application to place her into nursing care was declined  despite her increasing frailty and risk. Had further fall prevention measures been put in place, and had nursing care been provided, her falls may have been prevented 
4CIRCUMSTANCES OF THE DEATH 

Betty was admitted to Darnell Grange on 5 May 2020. She mobilised with a Zimmer frame and was a high risk of falls.

Her falls risk was initially managed with an ultra-low-profile bed. A sensor mat was later put in place, but it is not known when. 

There was no available evidence about any falls prior to 30 March 2022.

She fell, unwitnessed, on 30 March 2022, 23 May 2022, 23 September 2022 and 23 July 2023. 
As a result of the fall on 23 July she sustained a right orbital fracture.

She fell again, unwitnessed, on 9 September 2023 and was admitted to hospital. The Court heard Darnell Grange felt they could not accommodate her within their  residential unit any longer and a nursing placement was required. The funding for this  was declined and Darnell Grange accepted her back onto their residential unit despite accepting they could not manage her falls risk. 
She fell again on 30 September 2023 and 16 December 2023.

On 24 January 2024 her anti-coagulation medication was stopped by her General  Practitioner due to her frequent falls. Darnell Grange continued to administer the  medication until her fall on 13 February 2024 when concerns were raised about this by attending paramedics. 

She fell again on 13 February 2024 and twice on 16 March 2024. All but one of those falls was unwitnessed. 

On 16 March 2024 she sustained an osteoporotic fractured neck of femur. After the second fall that day, was moved into her bed by staff. It cannot be said whether the fracture was caused by the fall or by Betty being moved after the fall. 

She underwent a nailing of the right femur on 18 March 2024 and died in hospital on 19 March 2024 with a cause of death provided as:

1a. Osteoporotic fracture of right neck of femur (operated) and frailty of old age.
2. Vascular dementia and heart failure.

After every fall her care plan and falls risk assessment were reviewed and no changes made. 
5CORONER’S CONCERNS 

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In  the circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows. –

The Court heard that changes had been made to alleviate the concern of a risk that future deaths could occur including: 

i. Darnell Grange now have access to System One to be able to review prescribed medications. 
ii. All falls are now referred to the occupational therapy team at their local surgery.
iii. All care plans are now reviewed with the local surgery and the resident’s family.
iv. Darnell Grange no longer admits those with a high risk of falls.

However, the Court also heard that the nurse involved in moving Betty into bed after  her fall on 16 March 2024 was from an agency. The evidence was that agency nurses are not trained on, or provided with, policies and procedures from Darnell Grange and therefore the nurse would not have known the policy was not to move a resident after  a fall but to keep them comfortable and preserve their dignity until medical assistance  arrived. The Court heard it was presumed from their nursing training they would know  not to move a resident after a fall. 

There is a clear risk of future deaths will occur if agency staff are not provided with  home specific training, policies or procedures, not least given that it cannot be said whether the fracture was caused by the fall, or by moving Betty after the fall. 
6ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.
7YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely by 11 December 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.
8COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 

i. Betty’s family.
ii. Care Quality Commission, Citygate, Gallowgate, Newcastle upon Tyne, NE1 4PA

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. 
916 October 2024 
Signature
Tanyka Rawden
H.M Senior Coroner for South Yorkshire (West)