“That Mr Yemm was placed into a totally unsuitable and unsafe residential setting”
Dated 2 Feb 2021, from the coroner for Norfolk. Sent to 3 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 30 Mar 2021. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated2 Feb 2021
- Deadline30 Mar 2021
- Published on judiciary.uk4 Feb 2021
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Adult Social Services | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Norfolk County Council | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Norfolk and Norwich University Hospitals NHS Foundation TrustNamed in the report as “Norfolk and Norwich University Hospital” | Response publishedPublished on judiciary.uk in February 2021. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
That Mr Yemm was placed into a totally unsuitable and unsafe residential setting. Shortly after his arrival, the next day, the manager contacted Mr Yemm's social worker and told them they couldn’t look after him properly. Despite this he was left in this care home. wrote to the Director of Adult Social Services asking for help in finding a suitable placement and did not receive the courtesy of a reply. She was also told that after his falls that he had hairline fractures of his left hip before the fall in hospital. The hospital dropped Mr Yemm off back at the care home without any warning after being informed that they could not have him back. He was also discharged on insulin which the home could not administer as they do not have trained nursing staff. That he was able, in a cohorted patient bay, to climb past raised bedrails, he did not have a lowered bed, whilst staff were present. A cohorted bay has extra staff to deal with challenging patients and fell fracturing his hip, necessitating surgery. For the whole of his stay Mr Yemm was agitated, confused anxious and distressed, he had to move wards because of the need for surgery which further exacerbated his condition. (1) The care home placement (2) The hospital discharge despite being told they couldn’t send him back, and just leaving him there. (3) The in-patient fall and care of dementia patients.
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, 2021-0024
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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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
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