James Siddons: Prevention of Future Deaths Report
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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
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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 | |
1 | ![]() I am Liliane Field, assistant coroner, for the coroner area of London Inner South |
2 | ![]() 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 |
3 | ![]() 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. |
4 | ![]() ![]() 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. |
5 | ![]() 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 |
6 | ![]() In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. |
7 | ![]() ![]() 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. |
8 | ![]() 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. |
9 | ![]() Liliane Field Assistant Coroner |