We acted for a national care home provider after a service user suffered a fall and subsequently died. As the death was not expected, it was referred to the Coroner for investigation. We assisted our Client by obtaining Interested Person status for them which allowed them to have access to documentation, including the post mortem. It also allowed the Home to ask witnesses questions at the subsequent hearing.

We helped our Client’s staff to put together witness statements about the service user’s care and what and happened on the night of their death. This helped to provide additional detail and background that the care records did not, in isolation, provide. In addition, we helped the Home manager put together a witness statement which set out what the Home had done following the death of the service user to improve systems at the Home.

At the inquest, we instructed a barrister who robustly but sensitively questioned witnesses to help ensure all relevant information was conveyed to the Coroner. The barrister also made submissions on the conclusion that was open to the Coroner to find.

The Coroner reached a narrative conclusion noting that the service user died following the fall, but that the death was accidental. No Prevention of Future Deaths report was issued as the Coroner was satisfied that the Home had taken steps to minimise such a fall happening again, after they had heard from the Home manager.

We liaised with a public relations firm to ensure that press coverage was kept to a minimum.