Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0250, written 6 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 | 6 Sep 2013 |
|---|---|
| Reference | 2013-0250 |
| Deceased | Peter Pattinson |
| Coroner | Derek Winter |
| Coroner area | Sunderland |
| 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.
Derek Winter Senior Coroner for the City of Sunderland REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Mr Ted Smith Chief Executive Officer European Care Group Two Parklands Business Park Birmingham Great Park Rubery West Midlands, B45 9PZ CORONER | am Derek Winter, Senior Coroner for the City of Sunderland 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 21/03/2013 | commenced an investigation into the death of Peter Pattinson aged 71. The investigation concluded at the end of the inquest on 05/09/2013. The conclusion of the inquest was: - ‘Natural Causes’; medical cause of death being: - la Bilateral Pheumonia ll Congestive Cardiac Failure; Chronic Renal Failure; Chronic Obstructive Pulmonary Disease CIRCUMSTANCES OF THE DEATH Mr Pattinson who had complex medical needs was hospitalised from the 29" November 2012 until 30°" January 2013 when he was discharged to Cedar Court Care Centre, Portland Avenue, Seaham SR7 8BT. However he was readmitted to hospital on 4" February 2013 after he had fallen from his bed at Cedar Court Care Centre. Despite on-going care at the hospital he died on the 19°" March 2013. CORONER’S CONCERNS 1. The concerns expressed by the family and their requests for Mr Pattinson’s bed rails to be raised were not acted upon or documented, and were not subject to a risk assessment. 2. The repair to the bed rails of Mr Pattinson’s bed was not actioned in a timely way. 3. There were missing daily statements from the file (27 November 2012 18:00 hrs to 29" November 2012 18:30 hrs) 4. The daily statements that were provided were not paginated sequentially. Civic Centre, Burdon Road, Sunderland, SR2 7DN Tel 0191 5617843 | Fax 0191 5537803 | DX 60729 Sunderland www.sunderland.gov.uk/coroner ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you or your organisation 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 Monday 4" 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: - - Family - Cedar Court Care Centre - Care Quality Commission - City Hospitals Sunderland NHS Foundation Trust - Regulation 28 Archivist for Coroner Society of England and Wales 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, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. Dated this 6" day of September 2013 Aq Signature Senior Coroner for the City of Sunderland
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.
; a sy EUROPEAN CARE Group 21 October 2013 Private & Confidential Mr Derek Winter Senior Coroner for the City of Sunderland Civic Centre Burdon Road Sunderland SR2 7DN Dear Mr Winter, Mr Peter Pattinson - Response Regulation 28 Report | am writing in response to your Regulation 28 report regarding Mr Peter Pattinson dated 6 September 2013 and | set out below the actions that we have undertaken in order to address the concerns set out at paragraph 5 of your report. 1. Requests to raise bed rails not being acted upon or documented and not being subject to a risk assessment We have now undertaken the following actions: a. bed rail risk assessments are carried out within 24 hours of admission and are then reviewed monthly or when needs change. Any changes will be discussed with the service user or a family member; and b. all present staff in post will undertake training in the safe usage of bed rails and read European Care's “Safe Use of Bed Rails” policy, signing to confirm they understand the policy. All new staff will undertake this training as part of their induction and understand European Care’s policy on the safe use of bed rails. Competencies for all staff will be signed off by the manager, training coordinator and clinical lead and a record kept on their personnel file. Continuous understanding will be monitored in supervisions. 2. Repairs to the bed rails of Mr Pattinson’s bed were not actioned in a timely manner We have now undertaken the following actions: a. a daily checking system is now in place for a senior member of staff to visually check the condition of the bed rails and record this on the handover. This in turn is checked by the manager; European Care & Lifestyles (UK) Ltd Registered in Engiand. Registered No. 3856015 en» Two Parklands Business Park, Birmingham Great Park, fy INVESTORS Rubery, Birmingham, West Midlands, B45 9PZ i, oY . 4 YL IN PEOPLE T: 0844 980 3666 F: 0121 457 4460 tool www.europeancare.co.uk b. any defects regarding bed rails are to be reported and repaired immediately. All staff are now aware of how to report defects both within office hours and out of hours; and c. maintenance of bed rails will be untaken monthly in accordance with European Care policy by the maintenance manager and a record of this maintenance will be kept. 3. Missing daily statements from Mr Pattinson’s file All documentation relating to daily statements used are now numbered so pages cannot be mislaid. 4. Daily statements provided were not paginated sequentially Please see response to paragraph 3 above. Please be absolutely assured that European Care are committed to continuously improving our quality and care and the safety and wellbeing of all our residents is paramount. We therefore trust that the above addresses all your concerns fully and comprehensively however if you do require any further information or have any further concerns please do not hesitate to contact me. Yours sincerely, Director of Quality Development
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