“Islington Housing Options Derrick was provided with a wheeled walker to reduce the risk…”

The coroner’s concerns

Islington Housing Options Derrick was provided with a wheeled walker to reduce the risk of falls. Although’s Derrick’s temporary accommodation was ground floor, there were steps down from the building to street level and he was thus unable to manoeuvre the walker out of the property. Despite a social care letter of support, outlining concerns that his current accommodation was unsuitable and detailing Derrick’s health problems, the housing options team did not award him any medical points. Derrick required carers twice a day. He was also given a pendant alarm for emergencies. However, no key safe was installed meaning that even in an emergency, neither carers nor emergency services could gain entry to his flat. This was raised repeatedly by his family, carers and other professionals. Islington Adult Social Services On discharge from hospital on 3 February 2024 following a fall, Derrick was provided with a good package of care. On 23 February this changed to a reablement package. Derrick was not suitable for reablement because of his declining cognition and progressive dementia. The occupational therapist raised concerns that he was not suitable for reablement for these reasons and because there were no rehabilitation goals. There was an over-reliance on Derrick’s selfreporting which was inaccurate given his memory problems, and a 2 focus on him doing more for himself. He began losing weight because he was not eating, and he was not able to cope with self-care. Daryel Care & Islington Adult Social Services On 20 February Derrick suffered a fall. Severe bruising and swelling developed on his face over the following days but this was not recorded in his care notes by his carers and not escalated until his daughter raised concerns on 24 February. “No concerns” was written in Derrick’s care record and no consideration given to whether he needed to be reviewed by a doctor. Integrated Community Aging Team, Whittington Health Following MDT meetings due to concerns over Derrick’s increasing deterioration and ability to cope with his own care needs, the Integrated Community Aging Team reviewed him on 6 March. They discharged him from the service on 12 March because he did not want to engage with their home assessment of him. Derrick was suffering from cognitive impairment as a result of previous strokes and newly diagnosed dementia. He also had a mental health history and was paranoid. This was compounded by problems he’d experienced with neighbours and cuckooing concerns meaning that at times, he didn’t feel safe at home. It does not appear that these were factored into his inability to engage with the team.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2025-0164

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0