Raymond Shepherd
30 Dec 2016 · Coroner Nigel Meadows · Manchester (City)
The coroner's concerns
1. poor record keeping in service user comment book
“The standard and detail of the record keeping in the Home Care Support Service User comment book was of very poor standard.”
2. lack of updated and reviewed customer file
“The Home Care Support Customer file does not seem to have been updated and reviewed.”
3. missed daily visits
“On-some occasions both daily visits were not undertaken.”
4. failure to notify GP or ambulance after falls
“From 18 January 2016 there were at least three occasions when the deceased had either reported a fall or been found having after fallen, but no action was taken to notify the GP or ambulance service.”
5. unaddressed self‑neglect and fall risk in high‑risk chronic health user
“The deceased was a service user with chronic health problems which affected his mobility and was at high risk of suffering a fall as well as self-neglect. He reported not wishing to eat anything over a period of days which again should have triggered some concern.”
6. delayed referral leading to preventable fatal fall
“Over a period of some days there seems to have been a deterioration in his condition which could have been identified and steps taken to stop it by appropriate referrals to primary health care services. In the event that led him to having a further significant fall in which he fractured a femur as well as sustaining other injuries. This in turn led to a hospital admission but he was not fit enough to undergo surgery and died.”