James Siddons: Prevention of Future Deaths Report

Care Home Health related deaths

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Date of report: 30/01/2025 

Ref: 2025-0051 

Deceased name: James Siddons 

Coroners name: Liliane Field 

Coroners Area: London Inner (South) 

Category: Care Home Health related deaths

This report is being sent to: London Borough of Bromley | Mills Family Ltd 

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

1. [REDACTED], Director, Mills Family Ltd, Ashfield Lane, Chislehurst, Kent 
BR7 6LQ 
2. [REDACTED], Chief Executive, London Borough of Bromley, Civic
Centre, Stockwell Close, Bromley, Kent. BR1 3UH 
1CORONER

I am Liliane Field, assistant coroner, for the coroner area of London Inner South
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 10 February 2022 I commenced an investigation into the death of James Collier SIDDONS, aged 91 years. The investigation concluded at the end of  the inquest on 24 January 2025. The conclusion of the inquest was that Mr  Siddons died on 31 January 2022 at University Hospital Lewisham, London (UHL). The medical cause of death was recorded as 

1a Sepsis 
1b Aspiration pneumonia and pyelonephritis 
2 Ischaemic heart disease, osteoporosis, previous stroke, Alzheimer’s disease

I concluded with the following narrative
Mr Siddons died in hospital from sepsis to which he had become increasingly  vulnerable due to deteriorating life-limiting medical conditions.  He had been  admitted to hospital having sustained a fractured humerus whilst resident at a nursing home. 
4CIRCUMSTANCES OF THE DEATH

Mr Siddons had been admitted to UHL on 18 January 2022 having sustained a fracture of his left humerus at Sloane Nursing Home, Beckenham. The  precise circumstances of the injury have not been established. Mr Siddons  suffered from a significant number of co-morbidities including but not limited to Alzheimer’s disease, osteoporosis, ischaemic heart disease and previous  stroke resulting in very severe frailty. Mr Siddons made a good recovery from  the facture and was waiting for a new nursing home placement when he  developed raised inflammatory markers suggestive of infection. There was  radiological evidence of aspiration pneumonia to which he was vulnerable due todysphagia as a manifestation of late-stage Alzheimer’s disease. He had also developed pyelonephritis. He died suddenly from sepsis, his condition  having remained stable, despite appropriate treatment with antibiotics, on 31  January 2022. 
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. –

Mills Family Ltd (Mills)

1.   The investigation into the circumstances of Mr Siddons suffering a fracture was flawed such that lessons that might prevent an incident which could  result in a future death have not been learnt 
a.  It failed to explore all the scenarios that might have accounted for fracture. 
b.  It was in part delegated to a deputy manager without terms of reference 
c.   Mills Family senior management was not involved  
d.  The investigation’s conclusions were based on assumptions 

2.   Mills have a policy setting out a broad overview of the principles of investigation but no detailed guidance on how an investigation should be  conducted within its organisation 

3.   There is no routine investigation training for managers 

London Borough of Bromley (LBB) 

4.   Mills did not receive the request for the provider led report from LBB until almost a month after the incident. The investigation was started promptly  but had to be conducted without Mills being satisfied that all the relevant  issues were known 
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 28 March 2025. 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 Mr Siddons’ family. I have also sent it to [Lewisham and Greenwich NHS  Trust who may find it useful or of interest. 

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. 
930 January 2025
Liliane Field 
Assistant Coroner