Coroner's warning after death of Rainham care home dementia patient
PUBLISHED: 16:55 18 September 2014 | UPDATED: 16:55 18 September 2014
A coroner has warned of a "risk of future deaths" at a Rainham care home during an inquest into the fatality of an elderly dementia patient.
Nadia Persaud, senior coroner for the eastern district of London, ruled that 84-year-old Betty Kyle suffered a fatal brain haemorrhage after an accidental fall.
Ms Persaud said there had been “failings” at Fountains Care Centre, which looked after Mrs Kyle, but it was likely that her fall could not have been prevented.
Mrs Kyle died at Queen’s Hospital, Romford, in 2013.
Ms Persaud gave her verdict today at Walthamstow Coroner’s Court, after adjourning the inquest last week.
She said: “I am satisfied that the subdural haematoma was caused by the incident that led to Mrs Kyle being found on the floor on June 1.
“The bleed was subdural, which is associated with trauma, not subarachnoid. The hospital ruled out the possibility of a stroke.”
On June 1, senior nurse Caroline Odulami found Mrs Kyle on the floor in her room, sitting near to the bed.
She checked her over initially, but said she did not make further checks because Mrs Kyle had fallen asleep.
The inquest heard that staff were supposed to give patients who had suffered unwitnessed falls neurological examinations every 15 minutes for four hours.
Ms Odulami also said she did not know Mrs Kyle was at a high risk of having falls.
On June 2, Mrs Kyle was taken to Queen’s Hospital with leg pain and doctors discovered the subdural haematoma.
They decided not to operate and she died on June 14.
Mrs Kyle had suffered a previous fall in April 2013, after which a social worker recommended the installation of a sensory mat.
But this action was not taken and care home manager Veekash Bhowaneesing told the inquest he did not know why.
Making her verdict, Ms Persaud said: “My ruling is that Mrs Kyle died as a result of an accident.
“I will however be making a Regulation 28 report to the care home about the failings I have found.
“The evidence gives rise to a concern that there is a risk of future deaths.”