Suffolk woman's care home death preventable
"It was apparent there was a less than diligent focus on risk assessment and mitigation," said Mr Stewart.
Mrs Sore, who was admitted to a care home in 2017 and had atrial fibrillation and congestive heart failure, suffered a stroke in 2014 and fell and fractured her neck in 2020.By 2023 she only had mobility on her left side and needed hoisting into and out of bed and used an electric wheelchair.
After being deemed at risk of falling from her bed, it was ruled the railings on the side of her bed should be raised whenever she occupied it.But she fell out of her bed on 14 October 2023 and again on 20 October.On both occasions she was assessed and no obvious injuries were found, but on 25 October her condition deteriorated and she was taken to hospital.Clinicians determined the bleed on her brain was unsuitable for surgical intervention and she was discharged back to her care home for palliative care before dying of "accidental causes".
'Cultural problems'
Mr Stewart said the failure to secure the bed rails was the responsibility of multiple employees, "giving rise to the concern that this was a cultural problem" at the home.He also said staff would "regularly fail to implement" mitigation measures."In my opinion there is a risk that future deaths could occur unless action is taken," he said.
'Significant improvements'
Maven Healthcare, which acquired the home after Mrs Sore's death, told the BBC "significant improvements" had been made to the home."We remain fully committed to transparency, learning, and continuous improvement, and will continue to support the coroner's process," a spokesperson said."We extend our condolences to her family and loved ones."
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