Learning from Experience Database - Serious Case Reviews

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Mrs A (Worcestershire)

Mrs A’s body was discovered on 30 October 2009 in the grounds of her residential home A. Post Mortem revealed the cause of death to be hypothermia. Mrs A was an elderly person suffering with vascular dementia who received a range of health and social care services. In the terms of the Worcestershire Safeguarding Adults Protection Policy, she was a “vulnerable adult”. Mrs A was initially referred to Worcestershire’s Mental Health Services in September 2007 by her GP. He was concerned that she was experiencing problems with her memory and becoming disoriented and confused.  Mrs A resided at the care home for 2 weeks until she was found dead in the grounds of the Home on 30th January 2009. Post Mortem revealed that she had died from hypothermia. The Individual Management Review provided by the care home noted that on the evening of 29th January a fire door was found to be open. This was reported to a member of maintenance staff who secured it again. According to the report, the senior carer on duty failed at that point to conduct a headcount of residents. Further, during the night the senior carer on duty failed to check on Mrs A as was required by her care plan. It was discovered that she was missing the next morning.

Professional learning:

  • Staff should offer a carers assessment to main carers.
  • Arrangements are needed to ensure the continuing management of physical health conditions is not overlooked when a change in placement is made to address a mental health need.
  • Mental capacity assessments are undertaken when necessary and are appropriately recorded.

2009 October Serious Case Review regarding Mrs A (Worcestershire)