June Phillips

I am Louise Hunt, Senior Coroner for Birmingham and Solihull

On 18 May 2023 I commenced an investigation into the death of June PHILLIPS. The investigation concluded at the end of the inquest. The conclusion of the inquest was; accident

Mrs Phillips resided in a care home as she suffered from Alzheimer’s dementia and she took clopidogrel an antiplatelet medication to reduce the risk of clots. She required help with activities of daily living but remained mobile and would walk around the care home often at a fast pace. She  was assessed as at high risk of falls and had several falls due to her constant walking. At 23.05 on  07/04/23 she fell forwards in the hallway causing an injury to her forehead and back. She was  assessed and not thought to have any significant injury. 111 was called who advised further  monitoring. The following day she presented as normal however from 09/04/23 her condition  changed, and she appeared more sleepy and her mobility declined meaning she required more  assistance. On 12/04/23 she was assessed by a GP as part of the weekly ward round who noted  the fall and an injury to her right eye which was now very bruised but found no abnormalities or  changes so advised further monitoring. On 13/04/23 she was noted to be struggling to walk and  required a wheelchair and her mobility continued to deteriorate. After concerns were raised by her  husband, she was reviewed again on 17/04/23 by a GP. The GP was not advised of any  deterioration in her presentation and found no abnormal neurological signs but suspected she may have suffered a concussion from the fall. The plan was for her to be seen on the next weekly ward  round, and she was given eye drops for an eye infection. She was not added to the list for the  weekly ward round on 19/04/23. Mrs Phillips continued to deteriorate and require assistance and on 22/04/23 she was noted to be very sleepy. By 24/04/23 she was noted to be very unwell and  struggling to walk and eat and drink independently and after review by a GP she was admitted to  Birmingham Heartlands Hospital where a CT scan confirmed a large right sided traumatic subdural haemorrhage which was treated conservatively until her death on 30/04/23. It is likely she suffered  a head injury when she fell on 07/04/23 and that clopidogrel caused the initial injury to worsen over time but it is not possible to say whether earlier admission to hospital would have impacted on the  outcome. Based on information from the Deceased’s treating clinicians the medical cause of death was  determined to be: 1a       Traumatic Subdural Hemorrhage 1b 1c 1d II

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. –

1. The care home records were inaccurate and did not correctly reflect the deterioration in Mrs

Phillips condition after the fall. There is a concern that this creates a risk of further deaths.

1. The risk assessment for prevention of falls was not updated when it should have been after her  fall on 07/04/23 and when her condition deteriorated. There is a concern that this create a risk of  further deaths as risk assessments are not up to date.
2. The post falls investigation did not adequately investigate the circumstances of the fall. There is a concern that this creates a risk of future deaths as lessons are not learnt from incidents.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.