Findings into Mrs C serious case review released
Wednesday 19 September 2012
An independent enquiry into the death of a vulnerable Coventry lady has produced 12 recommendations about lessons that could be learned in the future.
Coventry's Safeguarding Adults' Board started a Serious Case Review into the circumstances leading up to the death of the lady - known as Mrs C - in early 2011.
The investigation focused particularly at the level and standard of care Mrs C received from Anchor, which owns and runs the housing with care complex where she lived, and Coventry City Council which was ultimately responsible for her care.
The mother-of-five, who suffered from Parkinson's disease, was found by staff at the home trapped between a bed grab handle and the side of her bed and was pronounced dead at the scene.
A bed grab handle provides help to individuals getting in and out of bed but is different to a bed rail that often stops people from falling out of bed.
The bed grab handle was issued to Mrs C about 10 years ago by Coventry City Council's equipment stores and went with her as she moved homes as her health deteriorated.
The risk of injury of such equipment is well documented within health and care environments but is widely available from major retailers costing between £20 and £30 and there are thought to be thousands in use in Coventry.
At the time of her death Mrs C's bed grab handle was not secured by additional cords to prevent it dislodging as it should have been. It was also attached to an electric bed which she elevated 45 degrees to help her get in and out of bed.
This too would have affected the stability of the bed grab handle which is why they are not recommended to be used with moveable beds.
Mrs C's mattress was bought by her family but the suitability of the bed grab handle was not assessed by occupational therapists or physiotherapists who visited her.
The report found that: "The grab handle apparently became 'invisible' to those who were working with Mrs C and providing her care.
"The tragic consequences of the lack of assessment and monitoring of the bed grab handle were not foreseen but the risk of this type of equipment was well documented.
"Staff who have routine contact with bed grab handles should be given awareness training in how they should be fitted and safely used."
It concludes: "That the bed grab handle was incorrectly installed indicates that Mrs C's death was avoidable."
Brian Walsh, Chair of Coventry's Safeguarding Adults' Board, stressed that a Serious Case Review is not about apportioning blame on an individual or organisation.
He said: "This review has carefully considered the circumstances involved in this case in order to gain an understanding of the lessons that could and have been learned.
"As a city, we take the issue of safeguarding adults very seriously and the most important outcome of any Review is to try and reduce the likelihood of this happening to anyone again."
All 12 recommendations from the Serious Case Review have either been implemented or are in the process of being implemented.
Three were multi-agency recommendations, three were for Anchor, three were for Coventry City Council, one was for University Hospitals Coventry and Warwickshire NHS Trust and two for Coventry and Warwickshire Partnership NHS Trust.
Mr Walsh added: "There is no evidence that any actions of the organisations involved directly caused Mrs C's death but it is clear that there are lessons that could and have been learned in the future to reduce the likelihood of these circumstances recurring."
Linda Watson, District Manager for Anchor, said: "This was a tragic but isolated accident and we pass on our condolences to the lady's family.
"The customer had been using the inappropriate hand grab rail for 10 years without incident and was living independently.
"Following this accident, staff immediately launched a programme to further raise the high standards of care for our customers. Care staff will inspect all equipment that customers bring with them if it poses a possible risk and a risk assessment will be carried out. The safety of all our customers is paramount."
An executive summary of the Serious Case Review can be found at www.coventry.gov.uk/safeguardingboard.
Anyone wanting advice or who may have questions about a bed grab handle, should contact Coventry City Council's Opal Assessment Centre on 024 7678 5252.