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Suffolk woman's care home death preventable
Suffolk woman's care home death preventable

BBC News

time3 days ago

  • Health
  • BBC News

Suffolk woman's care home death preventable

A woman's death could potentially have been prevented if care home workers had raised the rails on the side of her bed, a coroner has Sore died on 8 November 2023 after suffering a large subdural haematoma – a type of bleed on the 84-year-old had fallen from her bed at North Court Care Home, in Bury St Edmunds, Suffolk, twice before her death. In a Prevention of Future Deaths Report, Suffolk coroner Darren Stewart ruled it was "probable" the falls had made a "material contribution to her injury and death".Maven Healthcare said it was taking steps "to prevent a similar incident from occurring again". "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 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 she fell out of her bed on 14 October 2023 and again on 20 both occasions she was assessed and no obvious injuries were found, but on 25 October her condition deteriorated and she was taken to 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 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." Follow Suffolk news on BBC Sounds, Facebook, Instagram and X.

Coroner warns care home of ‘cultural problem' after patient's double bed fall
Coroner warns care home of ‘cultural problem' after patient's double bed fall

The Independent

time4 days ago

  • Health
  • The Independent

Coroner warns care home of ‘cultural problem' after patient's double bed fall

A coroner has told a care home it suffers from a 'cultural problem' after a patient died shortly after falling from her bed twice in the space of a week. Sonia Sore, 84, fell onto the floor at North Court Care Home in Bury St Edmunds, Suffolk, on October 14 2023 after the right handrail on her bed was not raised. Despite staff subsequently noting that the rails should be raised when the patient was occupying the bed, she fell out the same side in the same manner six days later after no action was taken. A bleed was then identified on Mrs Sore's brain after her condition deteriorated and she was taken to hospital. She died on November 8 2023 after receiving palliative care from the care home. Mrs Sore had been assessed as at risk of falling from her bed prior to either of the falls due to earlier health issues causing reduced mobility, with the raising of bed rails included in a management plan to address this risk. A narrative conclusion given at an inquest into her death found it was not possible to identify when the bleed on Mrs Sore's brain first started, but that it was probable the second fall on October 20 had 'made a material contribution' to her injury and death. 'The fact that the right-hand bed rail was not raised on Mrs Sore's bed meant that she was able to fall out of bed on the 20th October 2023 and this fact made a material contribution to the death,' it added. The inquest concluded Ms Sore died due to accidental causes. Her medical cause of death was given as a subdural haematoma. A nurse at the care home made an entry in Mrs Sore's notes confirming the requirement for her bed rails to be raised on October 17, but the right handrail was not raised following the note and was not raised at any point between the two falls. Darren Stewart OBE, area coroner for Suffolk, said it was apparent during the inquest that North Court Care Home had 'a less than diligent focus' on risk assessment and mitigation. He said: 'Despite risks being assessed, and mitigation measures identified, staff would regularly fail to implement the latter. 'In Mrs Sore's case this included the failure to secure the right hand side bed rail as identified in numerous risk assessments relating to mitigating her risk of falling from the bed. 'The evidence indicated that this applied in relation to the actions of multiple staff at the care home, not just a few, giving rise to the concern that this was a cultural problem at North Court Care Home.' A copy of a prevention of future deaths report were sent by the coroner to the care home's director of operations, with Mr Stewart adding: 'I believe you (and/or your organisation) have the power to take such action.' Copies were also sent to Mrs Sore's family, the Care Quality Commission, Mrs Sore's GP practice and the Chief Coroner for England and Wales.

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