Terence O’Connell

250 years
of excellence

gabbandco

Our ref. GFM/FC/31 14 October 2013
Your ref: LH/AMM/33350

Louise Hunt HMC

Her Majesty's Coroner for Bridgend
Glamorgan Valleys & Powys

Rock Grounds

First Floor

Aberdare

CF44 7AE

© Dear Ms Hunt
Terence O’Connell (deceased)

We represent the proprietor of Monkstone House Residential Home of 1 Locks
Common, Porthcawl, CF36 3HU and have been asked by them to respond to your
letter dated 28"" August 2013 in which you required a response to your Regulation 28
Report to Prevent Future Deaths.

We note that in paragraph 5 you have raised three specific and particular concerns
and you have asked for a response to each of these, which we will now deal with as
below.

1 Communication Failure

You have indicated that in your view there was a communication breakdown
between the care home, the district nurses and the out of hours GP service on

€ 3" May 2013 resulting in Mr O'Connell not been seen by any clinical staff. With
respect, our clients do not accept that there was a communication problem
between the three parties who you have indentified. The communication
breakdown (assuming that such was the case) was between the district nurses
and the GP out of hours service.

On 3% May our client's staff contacted the district nurses on three separate
occasions during the evening. There was also a series of conversations
between the out of hours doctor and district nurses which our clients have been

made aware of. Our client's staff also spoke to the family of the late Mr
O'Connell on three separate occasions. a O'Connell's
son in law) was the person who was spoken to and there are phone records
available to prove this.

RECEIVED
15 OCT 2013

Partners Consultants Associates Oid Bank House Beaufort Street Crickhowell Powys NP&8 1AD
Te! 01873 810629 Fax 01873 810485 DX 100751 CR ELL

E-mail crickhowell@gabb.co.uk

www.gabb.co.uk

The last phone call to ME was at 12.40am. During the course of this
telephone conversation a senior member of staff at Monkstone House informed

2 neither the district nurses nor the out of hours GP was going to
attend to Mr O'Connell at Monkstone House. did not want to
arrange for Mr O’Connel! to go to A&E. informed the member of
staff that he had spoken to the GP out of hours and he was happy for Mr
O’Connell to remain at Monkstone House and he would ring in the morning to
see what progress had been made. Staff at Monkstone continued to monitor Mr
O'Connell throughout the night and there is documentation available to confirm
this. No concerns were noted during this time.

Notwithstanding this, the Morikstone House policy has now been changed with
regard to clinical assessment. The effect of this is that if a health professional
(either district nurse or GP) will not attend Monkstone House within one hour of
being called, the patient will be sent to the local A&E Department.

Direct monitoring of all input and urinary output

The late Mr O’Connell was a gentleman who remained in his room throughout
his stay. He did not interact with any other residents or take meals in any of the
dining rooms. He would call for assistance when necessary. His routine was to
watch TV all day, only leaving his room to smoke. The information given to
Monkstone House by his family detailed his daily routine, with no concerns with
regard to his catheter. Accordingly, it would have been difficult to monitor his
urinary input and output as his supply of fluids was supplied by his family and
kept in his room, which he drank at his leisure. Also, the information that
Monkstone House received from Social Services, provided by his social worker,
did not provide any express instructions regarding Mr O’Connell’s
catheter or fluid input and output and only reference to his catheter being
emptied three times a day. In addition, there was no mention of any concern
made by his family or professionals regarding past or present problems with his
catheter before or during his admission to Monkstone House.

Notwithstanding this, the Monkstone House policy has been reviewed following
Mr O'Connell's death. The catheter care policy has been reviewed and all staff
have now been given extra training. In addition, urinary input and output
monitoring charts have been put in place for all clients. The Monkstone House
Policy and procedures which are now in place have also been reviewed and
approved by CSSIW, as documented in Monkstone House’s recent inspection
report which took place in August 2013.

3.‘ Failure to undergo clinical assessment

From the Friday to Sunday Mr O’Connell was monitored by staff at Monkstone
House and this was recorded in Monkstone House’s daily logs. Mr O'Connell
was checked hourly throughout the night and his family were kept informed of
his condition. No concerns were expressed and no visits were made by the
family. Senior staff followed the family’s decision not to send Mr O’Connell to
A&E. However, if senior staff felt at any point that Mr O’Connell’s condition was
deteriorating any further, then medical advice would have been sought
immediately, notwithstanding the fact that Mr O’Connell’s family had requested
that he should not be admitted to hospital. Throughout the period from Friday to
Sunday Mr O’Connell’s catheter was draining. Mr O’Connell appeared to be his
normal self and in a jovial mood, evidence of which is contained in his daily
records. His condition only began to deteriorate on Sunday to the extent that
emergency treatment then became necessary.

Mr O'Connell's daughter arrived at Monkstone House at 12.40pm to pick Mr
O'Connell up to return home. She expressed concern to a senior member of
staff that Mr O’Connell was not himself. The senior member of staff,
accompanied Mr O'Connell’s daughter to his room where she
agreed that his condition had deteriorated since she had seen him last at 12
noon. The GP out of hours was called, however further deterioration was noted
by and an ambulance was called for by her.

An ambulance arrived promptly and Mr O'Connell left Monkstone House by
ambulance at approximately 1.40pm.

Following these events, Monkstone House have reviewed all of their policies and
procedures regarding GP out of hours, district nurses requests for visits etc. and the
appropriate action in summary has been taken:-

1 Telephone calls are now recorded to confirm the substance of all conversations
between families and all other professional agencies.

2 Catheter policy and procedure has been reviewed; fluid input and output has
been revised and approved by CSSIW.

3. Meetings have been held with senior staff and if there are any concerns
regarding clients, staff are to seek medical advice, ensuring that all clients are
seen by a professional. If, for whatever reason clients cannot be seen at
Monkstone House and if out of hours GP and nurses will not attend, Morikstone
House will send the client to A&E department for assessment as soon as
practical.

4 Monkstone House is no longer offering respite facilities to clients.

In conclusion, we are attaching a copy of the Protection of Vulnerable Adults Strategy
Meeting minutes, which took place on 18" September 2013 regarding Mr O'Connell
together with some other additional policy and procedure documents which are
relevant to this matter. These are:-

e Policy and Procedure for Catheter Care

e Policy and Procedure for a client needing clinical assessment
e Pre-Admission Assessment Form

e Fluid Balance Chart

e CSSIW Inspection Report August 2013

We trust that the above information will be of assistance and if there anything further
we can assjst you with in dealing with, please do not hesitate to contact us.

Yowts faithfully

PROTECTION OF VULNERABLE ADULTS
STRATEGY MEETING

18" September 2013, 3pm, Pyle Life Centre
Terence O’Connell (Deceased)

Date, Time and Venue:
Name of Vulnerable Adult:

Social Services ID No: 310476
Date of Birth: 05.06.1942
Date of Referral: 07.05.2013

1. PEOPLE PRESENT, APOLOGIES, NON ATTENDANCE

In Attendance:

Adrian Bradshaw
Russ Warwick
Karen Merrett

Designated Lead Manager, Chair
Adult Safeguarding Officer, BCBC
South Wales Police

Clive Bevan South Wales Police

Penny Evans Social Worker, BCBC

Paul Rowley Contract Monitoring Officer, BCBC

Liz Collier Integrated Community Network Manager (Locality Lead for
District Nursing)

Morag Liddell Operational Lead, ABMU GP Out of Hours

Dr Bryn John ABMU GP Out of Hours

Carol Rice Inspector, C.S.S.1.W.

Paula Aplin Manager, Monkstone House

Karen Davies
Miranda Evans

Apologies:
Gweirydd Williams
Phillip Stanton
Louise Barraclough
DC Clayton Ritchie
Mark Adams

Monkstone House
Admin Support

Senior Environmental Health Officer, BCBC
Head of Environmental Health, BCBC
Operational Team Leader District Nursing, ABMU
South Wales Police

H.M. Coroners Officer

PURPOSE OF THE MEETING

Adrian Bradshaw welcomed everyone to the meeting and introductions were made.
The meeting is held under the Wales Interim Policy and Procedures for the
Protection of Vulnerable Adults.

The issues discussed are confidential to the members of the meeting and the
agencies they represent. They will only be shared in the best interests of the
vulnerable adult.

Minutes of the meeting are circulated on the strict understanding that they will be
kept confidential and stored securely.

Name: Terence O'Connell
\D No: 310476

In certain circumstances it may be necessary to make the minutes of the meeting
available to the civil and criminal courts, solicitors, psychiatrists, other local authority
social workers or other professionals involved in the care of the vulnerable adult.

N.B. When you sign the attendance sheet/protection plan please note that you are
signing up to the above confidentiality statement.

The purpose of today’s meeting is to share information; consider issues relating to
the vulnerable adult referral and in particular the level of risk and to decide on a
course of action.

Mr Terence O’Connell sadly passed away on 5'" May 2013 at the Princess of Wales
Hospital.

3. NATURE OF ALLEGATION

The allegation is the neglect of Mr O’Connell during a respite stay at Monkstone
House Care Home between 22™ April 2013 and the 5" May 2013.

4. | MENTAL CAPACITY/CONSENT/VIEWS & WISHES OF THE VULNERABLE
ADULT AND/OR THEIR REPRESENTATIVE

Mr O’Connell was deemed to have capacity although no formal assessment had
been documented.

5. PRESENTATION OF REPORTS BY AGENCIES

As a result of the first POVA Strategy Meeting on 15'" May the police and local
authority carried out a joint investigation regarding the sudden death of Mr O’Connell.

Karen Merrett presented a report for the POVA panel in relation to Mr Terence
O'Connell following a period of respite at Monkstone House Care Home in Porthcawl
and into the allegation of events prior to his death - at the time it was thought he had
capacity. Statements were taken from a large number of witnesses and included
family members, staff working at Monkstone House and the on-call District Nurses
and GP working on Friday 3° May 2013. The information obtained from the
statements allowed the police to formulate a report that was presented at today’s
meeting.

From the statements and the evidence, the investigators concluded that there was no
criminal element regarding the death of Mr O’Corinell. However, from the decision
made by Her Majesties Coroner during the inquest there had evidently been a
missed opportunity by agencies to provide adequate care to Mr O’Connell which may
have prevented him from passing away.

Statements maintained the events leading up to his death showed no signs of severe
illness, Mr O’Connell had been smoking and laughing with the staff at Monkstone
House. However from the report there were a lot of missed opportunities and
concerns.

Name: Terence O’Connell
ID No: 310476

The police felt whilst there is no Criminal element in the enquiry there are several
important matters that need to be addressed to prevent a similar future incident
occurring.

Russ advised under policy and procedure and due to missed opportunities this Adult
Protection should be considered as a Serious Case Review in view of lessons to be
learnt. The panel acknowledged the importance of agencies communicating and
working together.

Liz confirmed that she had been working with Chris Griffiths and Carol Killa since the
incident. She referred to the Out of Hours contact, and at no point did the District
Nurse refuse to attend — the problem was assessed and there was nothing they
could do as the Catheter was patent and draining. Karen Merrett confirmed the
District Nurse did maintain this in her statement.

It appears that there had been a breakdown in communication between the GP and
District Nurse Out of Hours and a number of situations arose. Subsequently,
Clinician to Clinician changes have been implemented in respect to the Out of Hours
service.

Dr Bryn John outlined that the GP Out of Hours service is based in Swansea but
there are 2 GP’s in each area of Neath Port Talbot and Bridgend and each GP can
identify patients waiting to be seen on screen.

In respect to Monkstone House, Paula advised that all policies and procedures at the
home have been revised, clear guidelines have been given and if there is no
response in future, the client would be admitted to A&E for assessment.

Russ advised on a handover recommendation; a course of action should be agreed,
even if the circumstances change someone should take responsibility. It is
understood structures are now in place.

Carol Rice confirmed she has been shown the new policies and procedures at
Monkstone House. Staff have reviewed training and changed some policies and
procedures — there are no issues with the changes in place and she is happy
Monkstone House can provide a level of care regarding a catheter.

Adrian reminded the meeting that no agency/person had been singled out as being
the alleged perpetrator, but a missed opportunity noted in Her Majesties Coronor’s
report, contributed to by neglect. Karen noted that Mr O’Connell was thought to have
had capacity.

District Nursing notes for Mr O’Connell were not provided by the family to the
home — Russ asked that care managers ensure client’s notes are provided for
any stays in care homes.

The District Nurses are currently on a 3 shift pattern, however they will be moving
towards a day and night service. The nurses covering the day/evening will therefore
be familiar with their clients and they will have specific shifts in order to provide
continuity of care.

Paula informed the panel she has ceased respite stays at Monkstone House.
Name: Terence O’Connell
ID No: 310476

6. INFORMATION ABOUT THE ALLEGED PERPETRATOR

No individual person(s)/agency is responsible, issues relate to multi-agency working
and communication.

7. INVESTIGATION
Completed.
8 RISK ASSESSMENT

No Risk to this adult as sadly he has passed away, however we have to consider risk
to others in this care setting and any other care setting agencies may support. Risk of
reoccurrence of events unless clear structures are in place which would ensure
matters of this nature do not re occur when agencies are required to provide support.

9. INDIVIDUAL/GENERAL VULNERABLE ADULT PROTECTION PLAN/SUMMARY
OF AGREED ACTIONS

1. Clear instructions to be provided to clinicians involved with ill patients/residents
that they are to speak directly to each other and agree on a course of action and
identify who accepts responsibility for the patient/resident - ABMUHB

2. If the service provider has no response from clinicians involved in the care of the
ill patient/resident then they should consider emergency admission to hospital.
This should be incorporated in Policy & Procedure and should provide clear
guidance to Care Staff — Service Provider

3. BCBC Adult Services to ensure that Care Managers ensure that records (District
Nurse Notes etc.) are provided to the service provider upon acceptance in a care
setting whether that be for a respite period or permanent residence. Care
Manager should link with relevant persons (including family)/agencies to ensure
that records are kept with the service user. In particular when records are kept at
the home address of the service user - BCBC / DLM

4. The service provider should request the relevant records of any service user they
accept in the care setting whether for respite purposes or for permanent residency
— Service Provider

5. Agencies to reply to request from Her Majesties Coroner and inform her what
actions have been undertaken to prevent/minimise risk of reoccurrence of events.
These actions to be shared with POVA process in review meeting which will be
arranged in due course — All agencies requested

6. Matter to be referred to the Western Bay Safeguarding Adult Board (WBSAB) for
consideration of this matter being subject of an Adult Serious Case Review
Process — DLM & Russ Warwick

Name: Terence O'Connell
ID No: 310476

10.

11.

12.

13.

FEEDBACK TO VULNERABLE ADULT/FAMILY/CARERS/REFERRER/OTHERS
Family members will receive an update from this meeting, however they will not
receive the notes presented by Karen Merrett in terms of the investigation - DLM &
Russ Warwick

OUTCOMES OF ALLEGATIONS
Liz Collier, Dr Jonn and Morag Liddell felt the allegation was likely on the balance of
probability but the consensus of opinion was a matter of Proven. Proven was
therefore agreed.

NOTE CONCERNS AND DISAGREEMENT

DATE OF NEXT MEETING

Tuesday 5th November, 2pm at Pyle Life Centre.

Name: Terence O’Connell
ID No: 310476

Policy and Procedure for Catheter Care

1. All staff must be aware of policy content and control measures required
to minimise infection and risk of harm to any client with an indwelling
urinary catheter.

2. Any clients with a catheter must have the necessary documentation
district nurse notes at Monkstone house. Carers are to seek advice from
district nurses at all times.

****D/N notes are to be brought in with the client on admission****

3. ONLY district nurses are to carry out any procedures with indwelling
catheters. Care assistants are only permitted to empty the bag.

4. Strict hygiene procedures to be carried out at all times, gloves and
aprons to be worn when attending to catheter. Hands must be washed
prior and after handling the bag.

5. The bag/urine must be disposed in an appropriate manner. The bag is to
be placed in a yellow bag in soiled waste disposal. A single use
disposable container must be used for each client, avoiding contact
between urinary drainage bag tap and container.

6. All documentation, (fluid balance chart), must be completed
immediately after emptying, input and output must be recorded to

monitor to daily total of intake and output, along with any concerns,
where the district nurse can be informed immediately.

7. The colour and flow of the urine must always be documented.

8. Ensure the tap is in the appropriate position after emptying to avoid any
spillage.

9. Ensure the client drinks adequate amounts and stays hydrated.

10.Monitor for any signs of infection. All staff are to familiarise themselves
with symptoms. These could be decreased output, pain, temperature,
and change in urine colour/blood. If any of these symptoms are noted,
medical advice should be sought.

11.Any concerns where medical advice needs to be sort, ring prime care.
Note the time of the call. If you have not received a response within 30
minutes, repeat the call. If after another 30 minutes, there is still no
response, arrange to take the client to A and E.

Policy and procedure: in the event of a client being
unwell/funny turns etc

If a client is unwell or has funny turn: monitor and if you
have any concerns, call the GP or prime care for advice.

If you are waiting for feedback from prime care and they
have not responded within 30 minutes, repeat the call for
advice. If you have still not received a response from
prime care after another 30 minutes, arrange for the
client to go to A and E.

If at any time, the client suffers any further
deterioration, ring for an ambulance
immediately.

Document any advice given in general recordings and
inform next of kin.

If a client has to go to hospital, follow admission
procedures.

If in doubt seek medical advice always.

Pre-Admission Assessment Residents File 17/01/11

SERVICE USER
PRE-ADMISSION
ASSESSMENT

PLEASE COMPLETE ALL PAGES AND SIGN BELOW

NAME:
SIGNATURE:

Page 1 of 7

Pre-Admission Assessment Residents File 17/01/11

ADMISSION DETAILS

REASONS FOR ADMISSION

SERVICE USERS PERSPECTIVE FOR ADMISSION INTO CARE

FAMILYS PERSPECTIVE FOR ADMISSION

OTHER AGENCYS PERSPECTIVE (please comment on social work, GP. Etc)

Page 2 of 7

Pre-Admission Assessment Residents File 17/01/11

HEALTH ISSUES

PHYSICAL HEALTH PROBLEMS (comment on past and present problems)

LAST SEEN BY THE GP

CONTINENCE ISSUES (PLEASE TICK APPROPRIATELY)

COTINENT.........
INCONTINENT.......... URINE........... DOUBLY...........
CATHETER........... COLOSTOMYV............

**** ANY DISTRICT NURSE NOTES MUST BE BROUGHT IN ON ARRIVAL****

MENTAL STATE (comment on past and present mental health problems)

SOCIAL AND EMOTIONAL ISSUES

Page 3 of 7

Pre-Admission Assessment Residents File 17/01/11

CURRENT MEDICATION (please state if person self-medicates

PLEASE LIST ALL CORRECT MEDICATION

WITH ANY WARFARIN TREATMENT, THE ANTICOAGOLANT BOOK MUST BE BROUGHT IN ON
ARRIVAL.

Page 4 of 7

Pre-Admission Assessment Residents File 17/01/11

SERVICE USER PERSONAL DETAILS

Title: Date of Birth:

Surname: Age:

Forenames: Known As:
Nationality/ Origin:

Address: First Language:
Religion:

Married/ Single/ Widowed/ Divorced

PRINCIPAL CARE DETAILS NEXT OF KIN
Name: Name:
Relationship: Relationship:
Address: Address:
Telephone: Telephone:
PRIMARY CARE TEAM
Doctor: CPN: Tel No.
Surgery:
Address: Chiropodist:

Telephone: Social Worker:

District Nurse: Clinic: Tel No.
Telephone: Other: Tel No.

HOSPITAL DETAILS (Inpatient)

Date of admission: Ward:

Date of planned discharge: Consultant:
ADMISSION DETAILS

Date of admission: Temp placement:

Residential/ Nursing Care/ Other Respite Care

Permanent placement: Room No:

Page 5 of 7

Pre-Admission Assessment Residents File 17/01/11

ADDITITONAL INFORMATION

SPECIALIST SERVICES YES NO COMMENTS
Occupational Therapy
Physiotherapy

Regular out patient appointments
Chiropodist

Dentist

Dietician

Speech Therapist

Community Psychiatric Nurse
District Nurse

Optician

Counselling

Palliative Care
Other

FINANCIAL DETAILS

Person responsible for finances Funding Details:
Name: Self Funding
Address: Part Funded
rs |
Relationship:
AGENT | APPOINTEE EPA | COURT OF PROTECTION
WISHES ON DEATH
SOLICITOR FUNERAL DIRECTOR
NAME NAME
ADDRESS ADDRESS
Tel No. Tel No.
Burial
Cremation

Special considerations to be made
Comments

Page 6 of 7

Pre-Admission Assessment

Residents File

17/01/11

ACTIVITIES OF DAILY LIVING

SOCIAL NEEDS

YES

NO

COMMENTS

Good social skills

Enjoys company

Enjoys group activities

Prefers to spend time alone

Maintain interests/ hobbies

Enjoys outdoor activities

Regular church goer

Member of any organisations

Enjoys reading

Enjoys listening to the radio/
music

Enjoys watching television

Is the person a welsh speaker

Other

—o

RELATIONSHIPS

YES

NO

COMMENTS

Strong family relationships

Long standing friendship

Enjoys forming lasting friendships
Enjoys going out with family/
friends

Regular visitors

COMMUNICATION

YES

NO

Difficulty in expressing
themselves

COMMENTS

Speech difficulties

Visual impairment

Wears glasses/ contact lenses

Any visual aids/ equipment
required

Hearing impairment

Wears a hearing aide
Any hearing equipment required

Other

Page 7 of 7

Fluid Balance Chart

Resident File 07/03/2011

Fluid Balance Chart

Date Time Input Output Comment
eg ACup= | eg 100ml E.g Draining/flow
08:00 am | 250 ml measuring jug
or mark out a Urine colour

disposable cup

|

Total Daily Intake

Total Daily Output

Any
Comments

Ocssiw

Arolygiaeth Gofal a Gwasanaethau Cymdeithasol Cymru
Care and Social Services Inspectorate Wales

Care and Social Services Inspectorate Wales

Care Standards Act 2000

Inspection Report

Monkstone House Care Home

1 Locks Common Road
Porthcawl
CF36 3HU

Type of inspection — Focussed
Date of inspection — 1 August 2013
Date of publication — 30 August 2013

You may reproduce this report in its entirety. You may not reproduce it in part or in any
abridged form and may only quote from it with the consent in writing of Welsh Ministers.

Please contact CSSIW National Office for further information
Tel: 0300 062 8800

Email: cssiw@wales.gsi.gov.uk

www.cssiw.org.uk

Version 1.1 07/2012

Summary

About the service

Monkstone House, owned and operated by J & P Residential Homes Ltd is situated in
Porthcawl, a short distance from the town centre. The home is within walking distance of
nearby small shops, pubs, takeaways and cafes. The building is set back from the main
road in its own grounds. The home enjoys views of the Bristol Channel. There are good
bus links and the motorway is only minutes away by car.

Monkstone House is registered to provide personal care and/or dementia/mental infirmity
care for up to 41 people over the age of 65 years. The home can also provide care for two
younger persons requiring personal care.

The registered manager and responsible individual is Paula Aplin.

This was a scheduled focussed inspection which took into account a recent concern
received by the Care and Social Services Inspectorate Wales (CSSIW) regarding catheter
care and fluid intake. The inspection focussed on Quality of Life.

What type of inspection was carried out?

Information was collated for this report following an unannounced visit to the home,
information held by CSSIW, scrutiny of the returned self assessment of service and annual
data collection documents. We spent time in the lounges observing staff with people using
the service, examined the care files of two individuals and had discussions with staff and
people resident at Monkstone House.

What does the service do well?
There was a warm welcoming atmosphere at the home and it was evident that the staff
make considerable effort to provide person centred care.

What has improved since the last inspection?

Parts of the building have been upgraded. Seven new ensuite facilities have been
provided.

There was a secure outdoor area with a waterfall which was very pleasant.

The laundry room had been extended.

What needs to be done to improve the service?
There were no areas of non compliance.

Version 1.1 07/2012

Quality of life

People using the service at Monkstone can be assured that they receive a good
standard of care. From discussion and care records we saw that people are supported
to make choices with regards to their care. People told us that staff treat them with
dignity and respect.

There was an activity co-ordinator at the home, however all staff were expected to assist
with the delivery of the activity programme. The day we visited, people were sitting
outside and enjoying the sunshine. The outside area of the home had been improved
and a water feature installed. This was a very pleasant area and was safe for people to
wander and easily accessible. We saw evidence of the activity programme that had
been delivered in July which included armchair aerobics, singers, bible reading, church
services, music for health, games and film afternoons. A fete was planned for the
following Saturday, which people said they were looking forward to. Previous fetes at
the home had been well supported by friends and relatives of people using the service.
There were life histories on people's files which outlined their preferences in regards to
activities and socialising. This was taken into account when planning the activity
programme.

We looked at the care records of two people using the service. The care plans were
detailed and reflected personal choice. The care documentation was supported by a
range of risk assessments, and both the care plans and the risk assessments had been
reviewed on a monthly basis. It was evident that for one individual whose condition had
deteriorated, the documentation had been reviewed often according to changes in her
needs. We visited this individual who looked well cared for and looked peaceful and
comfortable. We saw evidence that staff had visited regularly and were providing fluids
on a regular basis. Following the receipt of a concern regarding fluid intake and catheter
care, we saw that people using the service were receiving a good level of hydration and
that drinks were available throughout the home. We checked the records of one
individual with a catheter and he had a detailed care plan in place regarding his catheter
care. There was also an intake/output record and staff were carefully monitoring this,
and ensuring he had a good fluid intake and that his output was satisfactory. Staff had
received training on how to provide catheter care and we talked to two staff members
who described in detail how to care for this individual's catheter. We found no concerns
regarding catheter or provision of fluids for people at this visit. Records also showed
that the health and welfare of people using the service was promoted and timely input
from other health professionals was evident.

The staff had a good rapport with the district nurses who visited the home regularly and
also a good rapport with the local authority. The home was recently scored by the local
authority as part of their quality monitoring. The home scored 95.5% and should be
commended on their efforts to provide a high standard of care, services and facilities.

We talked to people using the service about the facilities and services at Mankstone.
They spoke very highly of the home and the staff, and were happy living there. They
commented positively on the food served and stated that they could order alternatives if
they didn’t like what was on the menu. Alternatives were offered at each mealtime and
on the day of the visit a roast chicken dinner was served with freshly cooked vegetables
and rhubarb crumble and custard for dessert. This looked and smelled appetising and
people were enjoying their meal. Staff closely monitor people during mealtimes and
observe what they are eating to ensure that they have a good nutritional intake.

Version 1.1 07/2012

We observed the care staff with people using the service. The care staff were trained,
experienced and skilled in recognising the needs of the people in their care. We saw
good relationships between staff and people using the service. People were supported
to go out and receive their visitors in private if they so wished and a visitor's room was
available to allow people to make tea and coffee for their quests.

Overall Monkstone provides a good standard of care to people in clean, comfortable
surroundings.

Version 1.1 07/2012

Quality of staffing

The inspection focussed on Quality of Life. CSSIW did not consider it necessary to
focus on Quality of Staffing on this occasion. However this theme will be considered at
future inspections.

Version 1.1 07/2012

Quality of leadership and management
The inspection focussed on Quality of Life. CSSIW did not consider it necessary to

focus on Quality of Leadership and Management on this occasion. However this theme
will be considered at future inspections.

Version 1.1 07/2012

Quality of environment

The inspection focussed on Quality of Life. CSSIW did not consider it necessary to
focus on Quality of Environment on this occasion. However this theme will be
considered at future inspections.

Version 1.1 07/2012

Version 1.1 07/2012

How we inspect and report on servicesWe conduct two types of inspection;
baseline and focussed. Both consider the experience of people using services.

e Baseline inspections assess whether the registration of a service is justified and
whether the conditions of registration are appropriate. For most services, we carry out
these inspections every three years. Exceptions are registered child minders, out of
school care, sessional care, créeches and open access provision, which are every four
years.

At these inspections we check whether the service has a clear, effective Statement of
Purpose and whether the service delivers on the commitments set out in its Statement
of Purpose. In assessing whether registration is justified inspectors check that the
service can demonstrate a history of compliance with regulations.

¢ Focussed inspections consider the experience of people using services and we will
look at compliance with regulations when poor outcomes for people using services are
identified. We carry out these inspections in between baseline inspections. Focussed
inspections will always consider the quality of life of people using services and may
look at other areas.

Baseline and focussed inspections may be scheduled or carried out in response to
concerns.

Inspectors use a variety of methods to gather information during inspections. These may
include

Talking with people who use services and their representatives

Talking to staff and the manager

Looking at documentation

Observation of staff interactions with people and of the environment

Comments made within questionnaires returned from people who use services, staff
and health and social care professionals

We inspect and report our findings under ‘Quality Themes’. Those relevant to each type of
service are referred to within our inspection reports.

Further information about what we do can be found in our leaflet ‘Improving Care and
Social Services in Wales’. You can download this from our website, Improving Care and
Social Services in Wales or ask us to send you a copy by telephoning your local CSSIW
regional office.

a Q. G IG Bwrdd lechyd Prifysgol
“Se oP N HS Abertawe Bro Morgannwg

University Health Board

Eich Cyf Your ref: INQ1530C %
Dyddiad/Date: 16" October 2013

PRIVATE AND CONFIDENTIAL

Louise Hunt

HM Coroner for Bridgend, Glamorgan & Powys
Rock Grounds

First Floor

Aberdare

CF44 7AE

Dear Mrs Hurt,
Re: Terence O’Connell Inquest (deceased) Schedule 5

| write in response to your letter of 28'" August 2013, with regard to the above matter.
The Health Board respectfully acknowledges and accepts the findings of the inquest
held on 22™ August 2013.

The Health Board held a Post Inquest meeting to discuss the verdict and practical
solutions to reduce future risk. Following the meeting the ABMU General Practitioner
Out of Hours Service and the District Nursing Services have provided the attached
action plan and reports.

The matters of concern relating to the Health Board were as follows:-

1. There was a communication breakdown between the care home, district nurses
and out of hours GP on the 3% may 2013, resulting in Mr O'Connell not being
seen by any clinical staff.

The Health Board has implemented a clear and accurate message sheet, SBAR
(Situation, Background, Assessment, Recommendation), for the switchboard staff at the
Princess of Wales Hospital to record all out of hours requests for District Nurses in
greater detail. The SBAR forms will ensure clear, audible records of referrals to the
District Nursing Service in the Bridgend Locality, supporting safe, high quality patient
care and the ability to review information and audit.

3. Mr O’Connell did not have any clinical assessment of his condition for 2 days
until his admission to hospital.

Bwrdd lechyd ABM yw enw gweithredu Bwrdd techyd Lleol Prifysgol Abertawe Bro Morgannwg
ABM University Health Board is the operational name of Abertawe Bro Morgannwg University Local Health Board
Pencadlys ABM / ABM Headquarters, 1 Talbot Gateway, Port Talbot, SA12 7BR. Ffon/ Tel: (01639) 683344

www.abm.wales.nhs.uk

Clinical Manager for the GP OOH Service has discussed this case on
two occasions with nurse management and agreed that in future all handover of care
should be made person to person and not via messages left at switchboard.

The District Nurses in Swansea and Neath Port Talbot Locality currently provide the GP
OOH Service with a weekend rota of the District Nurse’s on duty mobile telephone
numbers. lt is planned that this system will to be introduced in October 2013, in
Bridgend, once the new 24 hour shift pattern is introduced.

a 2: written to all the out of hours GP’s to remind them that they must
speak directly to the clinician who they wish to involve in the patient’s care and ensure
that responsibility has been passed to that person. It has been pointed out that this
procedure must be followed at shift changing times and outstanding problems are
communicated verbally and directly to the GP coming on shift.

| hope that the information provided satisfies the questions that you raised and
demonstrates the changes implemented and evidences how seriously the Health Board
has considered this matter.

Please do not hesitate to contact me further if my staff or | can be of any further
assistance to you in this matter.

Yours sincerely
PAUL ROBERTS

CHIEF EXECUTIVE

Enc. GP OOH report, DN’s report, DN’s action plan.

Qe GIG Bwrdd lechyd Prifysgol

Abertawe Bro Morgannwg

ae N HS University Health Board

ABMU GP OOH Service

c/o The Grove Medical Centre
6 Uplands Terrace

Uplands

Swansea

SA2 0GU

23° September 2013
PRIVATE & CONFIDENTIAL
Re Terence O'Connell - No 310476

The ABMU GP OOH Clinical Managers became aware of this case on 9" May 2013.
The clinical notes were seen by all Clinical Managers and I listened to all recorded
conversations on 10™ May 2013.

1st Call indicated that patient complaining of lower abdominal pain and pain where
catheter was inserted. Catheter was draining but not as much as usual. GP judged
this to be a catheter drainage problem and contacted District Nurse

2" call DN explained to the triage GP, FY she had talked to the home
already; she informed GP that she would not be able to flush the catheter as there
were no DN notes or equipment there and suggested that the home monitor the
fluid input and output. After a long discussion it was suggested by EEE that
there may be a UTI with some iil might need a washout and that
there may be notes available. agreed to locate the notes and the
nurse agreed to assess - actually said “yes we can sort something out that’s fine”
following EEE statement that “if you find any issues and he needs to go in
for a flush let us know”

3° Call HE phoned Care Home & was informed that son was already
bringing notes and equipment to the home.

4/5" Call DN informed that equipment has been delivered to the care
home but no notes and that she couldn’t do anything even if she attended. Home
visit agreed by

ABM Headquarters/ Pencadlys ABM, One Talbot Gateway, Seaway Parade, Baglan Energy Park, Port Talbot. SA12 7BR.
Telephone: 01639 683300 Ffon 01639 683300 FAX: 01639 687675 and 01639 687676

Bwrdd lechyd ABM yw enw gweithredu Bwrdd lechyd Lleol Prifysgol Abertawe Bro Morgan

ABM University Health Board is the operational name of Abertawe Bro Morgannwg University Local Health Board
www.abm.wales.nhs.uk

6" call made by OOH GP in error to son-in-law - meant to talk to care home

7” ca re-triaged call with staff. He suggested that the patient wouid
have to go to A&E for catheter change. Carer suggested that she should phone the
matron who may be trained in Catheter management

8 Call Matron declined to attend but son in law had just phoned the home to say
that he had found the DN notes and was bringing the notes down. She had phoned
the DN and was waiting for a rep|y. a sic that if for any reason the DN
could not visit he would be happy to do so.

9" cal attempted to contact the DN via POW switchboard. There was
split recording due to the patching of the call and 1 was unable to establish whether
there was a direct person to person conversation.

10" cal EE cated the Care Home. He said he had left a message for the
DN and he saw no reason for her not to call. He told (the care worker who
he had dealt with all along) that he was closing the cal! but if there was any
problem she was to contact OOH again.

The Clinical Managers agreed that the advice given by both

was reasonable at the time and that Jad “safety netted” the
patient in his final call. However all agreed that there was a communication
problem and that as he had not been contacted by the DN on duty
following the 8" call, should have checked with the DN or the Care home to ensure
that the patient had been seen.

OOH had requested on several occasions the statement from this DN and asked for
" reasons why she had not made further contact with after making the
decision that she would not visit.

I have discussed this case on two occasions with nurse management and agreed
that in future ali handover of care should be made person to person and not via
messages left at switchboard.

DNs in Swansea and NPT give OOH a rota of DNs on duty over the weekend with
mobile contact numbers. It is hoped that this system will be extended to Bridgend
when the new 24 hour shift pattern is introduced in October 2013. Between
Monday and Fridays contact is made with DNs via the Hospital Switchboards in each
of the three localities.

OOH had informed the DN Service in Bridgend that the most efficient way to

contact OOH Drs was to use the contact telephone number for the Primary care
Centre in Morriston a | rather than using the Primecare call
handling service as all such calls are logged as urgent by the OOH Reception staff

and responded to as rapidly as possible by the OOH GPs.

I feel that there is a lack of understanding of the ABMU OOH Service, particularly in
Bridgend and NPT. I have extended an invitation to the nurse managers in both
areas to the OOH admin office to see the recording and clinical systems and to visit
one of the OOH Centres to see the system in operation.

I have written to all GPs working for the OOH Service reminding them that they
MUST speak directly to the clinician who they wish to involve in the patient’s care
and make it clear that responsibility has been passed to that person. I have pointed
out that this procedure must be followed at shift changing times and any

outstanding problems are communicated verbally and directly to the GP coming on
shift.

—_ —

ABMU GP OOH Service

Report Regarding The DN Care of MR TO’C by the out of hours district nursin
service on 3% May 2013

At 7.30pm on 03.05.13 staff nurseff received a phone call via her

mobile to contact Monkstone House residential home.{fcontacted the home and
was advised that TO’C was a respite patient with an indwelling urinary catheter
insitu. TO’C was reported as having abdominal pain and penile burning not relieved
by analgesia but was otherwise his usual self. {J was informed the catheter was
draining clear urine and seemed to be working fine. As the catheter was draining
freely [lf assessed that the catheter was not blocked and the most likely cause was
a urinary tract infection. The carer advised there weren't any district nursing notes
available for Mr TO’C at the home.[then advised the carer she would speak to
the out of hours GP service and she then spoke to the out of hours receptionist for
the GP triage doctor to make contact with the care home to assess further.

At approx 19.50hrs firang the care home and advised the carer that the GP would
ring her shortly.

At approx 20:15hrs il received a phone call on her mobile from the cP
EE who requested I visit the care home and administer a washout or change
the catheter.Jbdvised she did not have any washouts as they are prescribed for
individual patients and she did not feel it was the appropriate course of action as the
catheter was draining freely and her assessment indicated an infection which
required a medical review. [J further advised that the reason there weren't any
district nursing notes at the home to verify the need for the catheter as the DN
service had not been alerted to Mr Oc’s admission for respite GE contacted
again and again requested that [visit and have a look at the catheter. J
declined and stated she thought TO’C needed a GP visit to rule out an infection and
a medical review of the cause of the abdominal pain. Mifaqvised she would attend
after the GP visit if the GP deemed it necessary.

At 20:25hrefE again phoned land asked if she would visit TO’C as the
district nursing notes were now being taken to the home. [contacted the care
home who again advised there we not any district nursing notes in the home and the
catheter was draining freely. Hi ano a on requested a GP attend to
assess the abdominal pain as the catheter was still patent and draining and the
patient needed a medical assessment, the GP visit was agreed.

Wspan of duty finished at 21:00 hours however owing to the workload that
evening she remained on duty lated contacted night staff nurse I at
approx 21:15hrs to inform her of what had happened and that the GP was going to
visit.

At approx 21:20hrs the carer from Monkstone rang MMM and stated the GP had
referred TO’C back to the district nurses as it was a catheter problem, the carer
further stated that the GP had informed her the district nurses were refusing to

attend. Wil informe the carer the district nurses were not refusing to but that from
the information they were given this was nota catheter problem and that a medical
assessment was required in order to find out the cause for his abdominal pain. ll
asked if the catheter was continuing to drain freely and she was informed the bag
was now % full. [iilwas then satisfied that the catheter was draining freely.

Asfl was aware that{J would be visiting patients at this point she contacted the

switchboard herself despite being off duty at 21:35hrs and it was confirmed that

they had received a call from the GP, had alerted [Jj to this and were waiting for
Mio ring them back.

At approx 22:20hrs the Health Care Support Worker accompanying il observed the
missed call on the mobile phone and rang switchboard to be informed that they didn’t
need to worry as the situation regarding TO’C had been sorted out we are unsure
why this information was relayed to fiat that time.

At approx 00:30hrs switchboard rang i asking her to ring Monkstone house.
then rang Monkstone House and the carer advised that nobody had visited and she
had been told to expect a visit from the GP. The carer advised TO’C was still
experiencing abdominal and penile pain and the catheter was draining ‘fine’.
explained that it was probably an infection which required antibiotics, which would
need to be prescribed by the GP. asked if the carer wanted her to ring the GP for
her but the carer said she was happy to do so herself lll epeated the conversation
out loud to her Health Care Support Worker colleague, which is her general practice.
The phone conversation ended with an agreement that the carer would contact the
GP.

This was the last contact made to the district nursing service regarding TO’C.

Conclusion

The district nursing staff made an appropriate assessment on the information
supplied by the care home i.e. that the catheter was draining freely, and therefore
the cause of the pain would not have been a blocked catheter.

There was a dispute between the district nursing staff and out of hours GP’s in
relation to the fact that this gentleman required a medical not a nursing assessment
at that point in time.

The communication between the Nurse and the GP was not clear in what was being
requested and the reasons why.

Messages were passed between switchboard and clinicians which reduced the
opportunity for clinical dialogue between the nurse and the GP which may have led
to a different outcome.

There is a gap in information available as to why the nurse fll was told by the
switchboard that she did not need to attend to MR OC at 22.20, however the system
for recording messages in Princess of Wales switchboard did not contain sufficient
details to audit the messages or identify the person responding to this call.

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