Samuel Brookes: Prevention of Future Deaths Report
Hospital Death (Clinical Procedures and medical management) related deaths
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Date of report: 15/04/2025
Ref: 2025-0190
Deceased name: Samuel Brookes
Coroners name: John Ellery
Coroners Area: Shropshire, Telford & Wrekin
Category: Hospital Death (Clinical Procedures and medical management) related deaths
This report is being sent to: Russells Hall Hospital
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: 1. [REDACTED]. Chief Executive, Russells Hall Hospital, Dudley Group NHS Foundation Trust, Pensnett Road, Dudley, West Midlands, DY1 2HQ | |
| 1 | CORONER I am John Ellery, H.M. Senior Coroner, for the coroner area of Shropshire, Telford & Wrekin. |
| 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 3 May 2024 I commenced an investigation into the death of Samuel Joseph BROOKES The investigation concluded at the end of the inquest on 24, 25 March & 9 April 2025 The conclusion of the inquest was; The deceased died following neglect to provide him his required care. |
| 4 | CIRCUMSTANCES OF THE DEATH Mr Brookes was discharged home from Russells Hall Hospital, Dudley on the 8 April 2024 where he had been admitted following a fall and long lie at home. The hospital arranged his transportation without rearranging his required care of two carers, four times a day. Mr Brookes, who was immobile and lived alone, was transported to his bed where he could not reach his pendant alarm nor his mobile phone, which was in another room. Mr Brookes was left unattended for two weeks until on the 22 April 2024 his grandson attended and found him unresponsive, wedged between his bed and the bedroom wall. An ambulance was called, sadly on arrival paramedics confirmed that Mr Brookes was deceased and his death was declared at 11:37 hours. It is not known when Mr Brookes died between the 8 & 22 April 2024. |
| 5 | CORONER’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 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. – (1) The hospital arranged for Mr Brookes transportation home without rearranging the required care as set out in paragraph 4 above. (2) There was no record or documentation or process to show or demonstrate that the care had been rearranged. (3) The transport company were responsible for transportation only and were not required to notify either the hospital, or if known, the care company of Mr Brookes’ safe return. It proceeded on the basis or assumption that care would have restarted within 4 hours or sooner. (4) Mr Brookes did not have his alarm pendant around his neck and nor was his mobile phone available (it was in another room). Accordingly when Mr Brookes got into difficulty he could not raise the alarm or call for help. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 10 June 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 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1. FBC Manby Bowdler LLP, Solicitors representing the family 2. Weightmans LLP, Solicitors representing Dudley Group of Hospitals 3. Outcome Care and Support 4. Cartello Ambulance – Transport Company 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 | John Ellery H.M. Senior Coroner Shropshire, Telford & Wrekin 15 April 2025 |