Thomas Godderidge: Prevention of future deaths report
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Date of report: 08/02/2024
Ref: 2024-0073
Deceased name: Thomas Godderidge
Coroner name: Robert Cohen
Coroner Area: Cumbria
Category: Other related deaths
This report is being sent to: Cumberland Council Adult Social Care
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: Cumberland Council Adult Social Care | |
| 1 | CORONER I am Robert Cohen, HM Assistant Coroner for Cumbria |
| 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made |
| 3 | INVESTIGATION and INQUEST On 3 March 2023 I commenced an investigation into the death of Thomas GODDERIDGE. The investigation concluded at the end of the inquest. The conclusion of the inquest was: Accidental death. 1a) Smoke Inhalation in combination with Chronic Obstructive Pulmonary Disease and Ischaemic Heart Disease |
| 4 | CIRCUMSTANCES OF THE DEATH Thomas Godderidge was 85 years old. He lived at [REDACTED], Carlisle. Mr Godderidge was frail and suffered from short-term memory loss. On 16th February 2023 a fire broke out at Mr Godderidge’s home. He died as a result of smoke inhalation. Prior to Mr Godderidge’s death repeated concerns had been raised about his risk of causing a fire. He repeatedly discarded lit cigarettes and had the habit of cutting paper into strips, which provided a ready source of fuel for a fire. |
| 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. During the inquest I heard from the carers who worked with Mr Godderidge. They reported to me that when concerns are raised about a service-user’s capacity there is not reliable and routine liaison between Adult Social Care and the care providers. I am concerned that this gives rise to a risk of future deaths. Care workers are very likely to see a service user more often than others. They have a particularly valuable perspective as to a person’s capacity. If their observations are not being considered then opportunities to provide care to vulnerable people may well be missed. Mr Godderidge’s carers also reported to me that in their experience consideration of capacity by Adult Social Care does not always reflect the possibility that a person’s capacity may be variable and fluctuating. I am concerned that this gives rise to a risk of future deaths if a person is considered on a ‘good day’ without understanding that their presentation fluctuates substantially over time. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you Cumberland Council 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 5th April 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. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the family of Mr Godderidge and [REDACTED] of Beacon Care. 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 | 8 February 2024 Robert Cohen HM Assistant Coroner for Cumbria |