Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0234, written 20 Sep 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Sep 2013 |
|---|---|
| Reference | 2013-0234 |
| Deceased | Joan Mary Jones |
| Coroner | Catherine Mason |
| Coroner area | Leicester City and South Leicestershire |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 4. The Manager, The Manor Residential & Nursing Care Home, 78-80 Lutterworth Road, Aylestone, Leicester, LE2 8PG CORONER | am Catherine Mason senior coroner, for the coroner area of Leicester City and South Leicestershire CORONER'S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INVESTIGATION and INQUEST On 9" October 2012 | commenced an investigation into the death of Joan Mary Jones. The investigation concluded at the end of the inquest on 18" September 2013. The conclusion of the inquest was that the cause of death was Bilateral bronchopneumonia due to locally advanced adenocarcinoma of the large bowel and Alzheimer’s dementia. A narrative, conclusion was recorded as follows: On the 23° September 2012 Mrs Jones became unwell and was seen by an out of hours doctor who diagnosed a viral infection. No further concerns were raised until the 30” September 2012 when she became unresponsive following an episode of aspiration the previous day. Again an out of hours practitioner attended. Mrs Jones thereafter continued to deteriorate and she died on the 1" October 2012 at The Manor and Residential Home, Leicester. Medical opinion is that when Mrs Jones initial illness had not showed signs of improvement after 2 to 3 days her General Practitioner should have been notified and it is likely that antibiotics would have been prescribed. This did not happen. As a result there was a missed opportunity to treat. However, medical evidence is that it is unclear whether the outcome would have been different. CIRCUMSTANCES OF THE DEATH Mrs Jones was a resident at The Manor and Residential Home, Leicester and was known to have Alzheimer’s dementia. An out of hours doctor saw her on the 23° September 2012 because the professionals caring for her were concerned about her being unwell. The doctor found her to have a runny nose and a slight cough. All vital signs were within normal range and a viral upper respiratory tract infection was diagnosed. Medication was not considered necessary and advice was given to encourage fluids and report any deterioration or further concerns. Mrs Jones continued to be cared for at the Home. On the 30” September those caring for Mrs Jones sought assistance from an out of hours advanced nurse practitioner. When he attended he observed that Mrs Jones had cold like symptoms and again considered them to be viral in nature. He noted a low blood pressure but was not concerned with it of itself. However, evidence revealed that he was not told of the doctor's visit the week before nor of the vital signs recorded at that stage. In addition, he was not infirmed of the aspiration. He said if he had he thought it was likely that he would have made arrangements for Mrs Jones to be admitted to hospital rather than instruct that she should remain at the Home. A Doctor from the practice that Mrs Jones was registered at, said that she would not necessarily have admitted Mrs Jones to hospital had she been faced with the same situation, but gave evidence that when Mrs Jones had not showed signs of improvement after 2 to 3 days following the medical attendance on the 23 September 2012, she would have expected the Home to have contacted the practice and a doctor would have visited. Furthermore, she stated that in her professional opinion, with the knowledge of Mrs Jones’ dementia and the care home setting, antibiotics would have been prescribed. However, she was not able to say whether on a balance of probabilities the outcome would have been different. However, she was clear in saying that there was a missed opportunity to treat and communicate with Mrs Jones' family and discuss an advanced care plan. CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — (1) The staff did not escalate Mrs Jones’ care when they should have done (2) The staff did not communicate all that was known to them and therefore attending health care professionals were unable to make fully informed decisions (3) Due to the lack of communication, an appropriate package of care was not put in place for Mrs Jones (4) These omissions (failure to escalate and the lack of communication with other attending health care professionals) together or alone, could in future circumstances cause or contribute to death. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by the 15” November 2013. |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, at the time of your response, about the release or the publicati your response by the Chief Coroner. 20" September 2013
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
:> :z:= U") 0 w (.) a:w \2e°I ~t il4.b.2r Nucs;ng Care Home 11th November 2013 Dear Coroner, Ref Mrs Joan Mary Jones st October 2012 Mrs Jones passed away at the Manor Care Home in Leicester. After the death On 1 of Mrs Jones an inquest was held on 18th September 2013. The verdict was a narrative one, with directive for the home's manager to take further action to ensure clear lines of communication after and out of hours GP visit. Also the home was to contact the family to meet up and answer any outstanding questions they had. On 19th September 2013 a memo was sent to all the unit leads to ensure that following any input from GP's and out of hours nurses, doctors the family must be contacted, that the communication sheet must be completed following any discussions, involvement with any health care professionals. That these communications sheets must be shared with any health care professionals and completed after each visit by health care professionals. These visits must be communicated to the family. It was also agreed that the home's manager would meet up with the family to discuss any unanswered questions. We have written to recorded deliver to ensure receipt of the letter. on 20 th September 2013 and 6 November2013, second time th Since we have not had any response from consultant, BKR Care Consultancy (BKRCC), to write and offer to arrange a meeting to discuss any questions with the family. BKRCC will be writing to by 18 Nov 2013. This will be sent recorded delivery. we have asked our independent care Cc: 78-80 Lutterworth Road ,Aylestone, Leicester, LE2 8PG Tel: 0116 2990225/229,Fax: 0116 2990257, E-mail themanorcarehome@hotmail.com --- Post Office Ltd. •••. Postoffi ce. co. uk TP:07 BP:09 SU: AA FAD: 1552171 06/11/2013 10:15 AYlestone 1 Earl Russell Street Ai 1es tone Leicester Leicestershire LE2 8LH Session Id: 3-490018 Txn Id: 1 Horizon Certificate of Posting Royal Mai 1 Signed For An 1te1 addressed as follows:- Building Ma1e or No: 46 PostCode/ZiP Code: LE86HU Barcode Mu1ber: KF483679187GB Has been accepted here today. Total Cost Of Services = fl. 70 It is i1portant that you retain this receipt as it is your Proof Of Posting. Please refer to Separate !eras and Conditions. Royal Mail Signed For 1st Class to deliver your Letter the next working day, This ls not a tracked service. Vou can check proof of receipt and Proof of delivery at www.roya1lail.co1 or call 08459 272100 quoting your reference nu1be1 For Products and services visit our web site et www. postoff ice. co. uk regerding Royal Mai 1 Withdraw cash over the counter lro1 your bank account at any of our branches(selected banks) It's free and easy Post Office Ltd. Vour Receipt FAD: 155217 Aylestone 1 Earl Russell Street Ayl estone Leicester Leicestershire LE2 8LH UAT REG No. GB 243 1700 02 Oate of Issue: 06/11/2013 10:15 SESSION: 3-490018 RMSF Letter 1 @ RMSF 1st Class 1 @ 0.00 1.70 TOTRL OUE TO POST OFFICE Ulsa Debit BALANCE FROM CUSTOMER Retai 1 0.00 1.70 1. 70 1.70 0.00 UISAOEBIT Card Mu1ber: *'*' **'* "'* 7014 Issue: ICC Auth Code: 119556 Merchant ID: 71188541 Ter1inal IO: 22542675 Application 10: A0000000031010 Transaction 10: 00-155217-3-2474820-1 Oate/fi 1e of Pay1ent: 06/11/2013 1O: 15 07113 Expiry: 07/16 EFT No: 4317 PAM Seq Mo: 00 A1ount: £1.70 Your account will be debited with the above a1ount. Cardholder PIM verified. Transaction conf1raed. 20t h September 2013 Dear , RE: Late Mrs Jones I write further to the coroner's inquest that was held on the 18t h September 2013. I was ade aware at the inquest that you had some concerns about the care that your mother Late Mrs. Jones received from the home, and would like to arrange a meeting so that we can discuss these and an internal investigation can commence. Please contact me on the numbers below or my mobile appointment can be arranged at your convenience to discuss these concerns. so that an I will look forward to hearing from you soon. Manager 78-80 Lutterworth Road ,Aylestone, Leicester, LE2 BPG Tel: 0116 2990225/229,Fax: 0116 2990257, E-mail themanorcarehome@hotmail.com
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