Vulnerable woman dies after fall in Sheffield care home causes haemorrhage

In a prevention of future deaths report, senior coroner Tanyka Rawden from the South Yorkshire (West) area said she had concluded the investigation into the death of Maureen Alison Woollen.

The report said Ms Woollen had been discharged from the Northern General Hospital in Sheffield to Deerlands Residential Home on October 2, 2023.

However, she added that while Ms Woollen had been at “a high risk of falls due to her underlying dementia and psychosis, her frailty, her limited mobility, the side effects of her medication and her previous falls”, the care home had failed to conduct a falls risk assessment upon her arrival.

The next day (October 3), Ms Woollen had been heard shouting and found on the floor in her room, the report said.

She had not been able to say how she ended up there and the staff had not identified any external injuries and had not sought medical assistance, Ms Rawden added.

The inquest found that on October 6, a staff member had noticed a “fresh big bruise and a lump on her right forehead and temple” and while the team leader had been notified and they had decided to call an emergency care practitioner, “the call was not made”.

Ms Rawden said between October 6 and October 13 there had not been references to Ms Woollen’s facial injuries in the care notes.

In the meantime, the inquest also found on October 11 staff had noticed a “decrease” in Ms Woollen’s food and drink intake – however, this had not been recorded in the care notes and medical assistance had not been sought either.

Two days later on October 13, the report continued, a general practitioner had been contacted “due to concerns from Mrs Woollen’s family and Deerlands Residential home that Mrs Woollen had experienced a recurrence of psychotic symptoms over the previous two days.”

The GP had attended the care home and found Ms Woollen “slumped in a chair” while he had been told that the facial injuries were from October 9 or 10 – but there had been no records of this in the care notes.

Ms Woollen had been admitted to the Northern General Hospital on October 13, the coroner said, where she had been diagnosed with an “intracerebral haemorrhage” – a type of stroke when a blood vessel in the brain ruptures. Ms Woollen died on October 31 as a result of this.

Ms Rawden, the coroner, said the evidence revealed matters giving rise to concern and added there was a risk that future deaths would occur unless action was taken.

She said: “The inquest found there were missed opportunities to conduct a falls risk assessment on Mrs Woollen’s arrival to Deerlands Residential home, to seek medical attention when she was found on the floor on October 3, 2023, to seek medical attention when a bruise on her face was noted on October 6, 2023, and to monitor the progression of her bruise.”

She added she was concerned there was no process in place to ensure medical attention is promptly sought for residents who need it, that care notes are not fully utilised, especially for the recording of injury and incidents, and that falls risk assessments are not being conducted on admission.

In response to this report – which had to be sent to the coroner 56 days after her findings -, a law firm on behalf of Sheffcare (the owner of the care home) said among the changes was the appointment of a new director of quality and care who had not been in post at the time of Ms Woollen’s fall.

The firm added she had been “implementing changes and improvements at the service”. Through her leadership, the response said, Sheffcare had reviewed its relevant policies and guidance including falls and risk assessment and admission policy.

The law firm said following Ms Woollen’s fall, a so-called “huddle” (an informal meeting at which matters to celebrate as well as concerns are raised directly with staff) was carried out and staff were reminded of policies about falls risk, documentation, and escalation.

They added: “Refresher training has been rolled out at all Sheffcare homes to include the completion of assessments prior to admission to the home and the importance of making detailed Person-Centred Software entries and maintaining daily care notes.”

Also, “a lessons learned” briefing was issued on June 21, 2024, to all homes to ensure that this matter was discussed across all the teams, they added.

The law firm said: “The admissions policy was reviewed and updated on July 1, 2024, to further outline that falls risk assessments are to be completed prior to or on admission to Sheffcare homes.

“This will include a person’s falls history and associated risks which could increase the risk of falls along with any falls which occur during the residency within a Sheffcare home.”

Mrs Woollen’s case (and the improvements and learning from it) will be discussed on August 22, 2024, at the quality committee meeting.