Coroner: CCG failed to provide appropriate care for vulnerable woman
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A coroner has said Havering Clinical Commissioning Group (CCG) failed to provide one-to-one care for a care home resident "at high risk of falls".
Ann Stillwell, 78, died on July 5 last year after complications from injuries she suffered in a fall on the afternoon of July 3.
An inquest concluded Mrs Stillwell's death was accidental, but area coroner Graeme Irvine wrote a report to prevent future deaths containing concerns around the circumstances.
The report said Mrs Stillwell was discharged from hospital to a care home - which is not named in the report - on June 22 after she suffered a broken leg in a fall the previous month.
Her discharge notes, Mr Irvine wrote, "recommended a high level of supervision, noting a significant history of falls, dementia and mobility issues".
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He said the care home manager asked the commissioner of Havering CCG to authorise funding for one-to-one care for Mrs Stillwell, which was rejected.
After the fall on the morning of July 3, in which she did not sustain any apparent injury, the manager renewed her application.
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Mrs Stillwell died after a second fall on that day.
Mr Irvine said: "Mrs Stillwell was at high risk of falls caused by a combination of factors; Mrs Stillwell's frailty, her dementia which limited her perception of risk, whilst at the same time made her forget her mobility restrictions, and her independent and assertive nature.
"One-to-one care would have been the only way in which the particular risk presented by Mrs Stillwell to herself could have been mitigated."
He wrote that action should be taken to prevent future deaths and sent the report to Havering CCG and the Department of Health and Social Care.
In a joint response, Barking and Dagenham, Havering and Redbridge CCGs said: "The CCG director lead and head of service met to discuss the coroner’s concerns and agreed actions to strengthen the management of requests for one-to-one care by care providers."
Changes introduced include a requirement for requests for one-to-ones to be sent to the head of service and a senior nurse assessor to provide a response within two hours.
In a letter to Mr Irvine, care minister Helen Whately wrote: "Departmental officials will work with NHS England to consider the specific circumstances of this case and whether further regional monitoring may be required."