Derrick Tully
28 Mar 2025 · Coroner Melanie Lee · Inner North London
The coroner's concerns
1. lack of emergency access to residence
“no key safe was installed meaning that even in an emergency, neither carers nor emergency services could gain entry to his flat”
2. inappropriate reablement placement for cognitively impaired individuals
“[the deceased] was not suitable for reablement because of his declining cognition and progressive dementia”
3. failure to document and act on clinical concerns
“No concerns" was written in [the deceased]'s care record and no consideration given to whether he needed to be reviewed by a doctor”
4. discontinuation of support due to non-engagement without addressing safety barriers
“They discharged him from the service on 12 March because he did not want to engage with their home assessment of him.”
5. environmental barriers to mobility aid use
“[the deceased] was provided with a wheeled walker to reduce the risk of falls. Although [the deceased]'s temporary accommodation was ground floor, there were steps down from the building to street level and he was thus unable to manoeuvre the walker out of the property”