Simon Graham
4 Oct 2018 · Coroner Emma Brown · Birmingham and Solihull
The coroner's concerns
1. lone working in respite homes
“Future Care & Social Care Association are a private company that own and run 7 respite homes and secure contracts with the NHS”
2. delayed emergency response
“Upon concern being raised by [the deceased]'s wife, the support worker was prevented from promptly checking on his wellbeing because he was with another resident at the medicine cupboard”
3. inadequate emergency assistance
“After forcing entry and finding [the deceased] hanging and in cardiac arrest the support worker got him down and commenced CPR”
4. mislabelled keys causing delayed access
“Support workers were using keys to check on residents in their rooms knowing that they were labelled incorrectly”
5. lack of suicide prevention training
“Future Care & Social Care Association have identified that support workers should undertake suicide prevention training”