Prevention of Future Deaths Report: Samuel Brookes (23 April 2025)

Summary

Samuel Brookes was discharged home from Russells Hall Hospital, Dudley, on the 8 April 2024 where he had been admitted following a fall and long lie at home. The hospital arranged his transportation without rearranging his required care of two carers, four times a day.

Mr Brookes, who was immobile and lived alone, was transported to his bed where he could not reach his pendant alarm nor his mobile phone, which was in another room. Mr Brookes was left unattended for two weeks, until on the 22 April 2024 his grandson attended and found him unresponsive, wedged between his bed and the bedroom wall. An ambulance was called, sadly on arrival paramedics confirmed that Mr Brookes was deceased and his death was declared at 11:37 hours.

Content

The Coroner in his report highlighted the following matters of concern:

• The hospital arranged for Mr Brookes transportation home without rearranging the required care.
• There was no record or documentation or process to show or demonstrate that the care had been rearranged.  
• The transport company were responsible for transportation only and were not required to notify either the hospital, or if known, the care company of Mr Brookes’ safe return. It proceeded on the basis or assumption that care would have restarted within 4 hours or sooner.  
• Mr Brookes did not have his alarm pendant around his neck and nor was his mobile phone available (it was in another room). Accordingly when Mr Brookes got into difficulty he could not raise the alarm or call for help.