A care home has been ordered to take action after staff failed to call 999 when an elderly resident fell and hit his head.

Arthur Edward Johnson, 85, suffered a brain haemorrhage after he fell at Oakridge House Residential Home, on Jefferson Road, on April 17, 2020.

He died at the Royal Hampshire County Hospital in Winchester three days later. 

Area coroner Jason Pegg opened an inquest into his death on April 21, 2020 where he concluded the death was an accident. 

But Mr Pegg was not satisfied with how the staff handled Mr Johnson's fall and he is now calling for change to prevent future deaths.

The coroner has written to Hampshire County Council, who is responsible for the care home, and the care home's manager, urging action to be taken. 

In a report, he wrote: “Oakridge House Residential Home is staffed by non-medically trained personnel. The ‘Post-Falls’ process/policy direct that 999/111 should be called when a head injury is suspected.

“The evidence at inquest indicated that where a head injury was considered a possibility 999/111 was not called. My concern is that the present process does not give adequate direction, provide sufficient clarity nor distinguish between “possible” and “suspected” head injury.

“It is not clear when 999/111 should be called. Further, I have concerns in relation to the training provided to assist Residential Home staff in the recognition of intracranial injury."

“In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action.” 

The inquest was started on April 21, 2020 and concluded on January 5, 2021.

Coroner’s report has also been sent to Adult Services of Hampshire County Council. 

The respondents have 56 days to update on actions taken or proposed.