Coroners Court- Prevention of Future Deaths Report

The Coroners and Justice Act 2009, paragraph 7 of Schedule 5, provides coroners with the duty to make reports to a person, organisation, local authority or government department or agency where the coroner believes that action should be taken to prevent future deaths.

These are known as prevention of future deaths (PFD) reports or Regulation 28 reports and are produced by the coroner if, during the investigations, the coroner identifies causes for concern that, if addressed, could prevent future deaths. The reports are addressed to whomever the Coroner is of the view can take desirable, remedial action(s).

The organisations identified are given an opportunity to reply to the report or to inform the Coroner why no action is being taken. The Chief Coroner is copied on all PRD/Regulation 28 reports, a copy is also provided to the family and it is also available to the public.

In this blog, Anoush Summers’ prevention of future deaths report dated 06 June 2024

is outlined together with the learning from the tragic death of Anoush Summer.

  • Anoush Summer was a frail lady who was prone to falls and who lived at home, alone
  • Carers visited her twice a day and she wore a wrist alarm.
  • On 06 January 2024, the wrist alarm was reported as broken and not working, but it was not repaired or replaced.
  • Sometime after 4.45pm on 11 January 2024, the deceased fell at home. She was found the next day, 12 January 2024 at 9am, by a carer. Anoush Summer was wearing her wrist alarm and was taken to Homerton University Hospital where she died on 14 January 2024 of hypothermia, aged 77.
  • The absence of a working wrist alarm prevented her from being found sooner and this probably contributed to her death.

On the 22nd January 2024 an investigation was commenced by the coroner into the death of Anoush Summers.

The investigation concluded at the end of the inquest on 6th June 2024 with a determination at the inquest that Anoush Summer had died as a result of hypothermia which resulted from a fall at home following a long lie.

From the evidence provided at the Inquest it was found that:

  • The wrist alarm had been reported as broken and not working on 6 January 2024, this was not replaced or repaired by the company engaged by the local authority to provide this service before the deceased fell at home between 11-12 January 2024.
  • At the time Anoush Summer fell, she was wearing her wrist alarm but could not use it to summon help because it did not work.
  • None of the carers who attended to Anoush Summer after 6 January 2024 ensured that steps were taken to replace the wrist alarm or report the matter to the local authority.
  • The last carer who attended to Anoush Summer before she died, on 11 January 2024, was not aware that the wrist alarm did not work as she had not read the care notes. No clear instruction was given to care workers about the extent to which they would be expected to read the care notes relating to service users.
  • None of the carers had been given any training, instruction, or guidance on the testing of wrist alarms to ensure they worked properly when attending to people to whom they were providing services.
  • There was no clear system identified between the company providing carers and the local authority, as to the duties and responsibilities of each in the reporting of faults with wrist alarms.
    The coroner was concerned that there is a risk of future deaths arising in circumstances when vulnerable people, who live at home and are reliant on wrist alarms which have been reported as not working but have not yet been repaired, may be unable to summon help.

The report was sent to local authority and the private company who provided the carers.

  • the need for robust case recording by the carers, so that all carers are aware of the current circumstances;
  • the need for good practice for carers to read recent case recordings so that they attend to care needs with up to date and most relevant information so that the carers can carry out their caring services effectively;
  • clear written communications between the carers, the service and the local authority;
  • a firm understanding of who is responsible for repairs and replacement of faulty safety devices; and
  • regular training and guidance for carers on the testing of safety devices.

Robust case recording, effective communication and ongoing training are often issues that are found to be lacking in PRD reports, Serious Case Reviews or Inquiries. The above key learning factors can be applied to any situation where care support is being provided either directly by the local authority or indirectly through a commissioned service provider.

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The contents of this guide are for information and are not intended to be relied upon as legal advice

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