Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0251, written 4 Oct 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Oct 2013 |
|---|---|
| Reference | 2013-0251 |
| Deceased | Walter Gordon Powley |
| Coroner | Donald Coutts-Wood |
| Coroner area | Leicester City & South Leicestershire |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Chief Executive (Mr David Behan), Care Quality Commission, Citygate, Gallowgate, Newcastle upon Tyne, NE1 4PA 2. The Registered Nursing Home Association (Chief Executive – Frank Ursell), John Hewitt House, Tunnel Lane, Off Lifford Lane, Kings Norton, Birmingham. B30 3JN 3. The Health and Safety Executive, Head of Health and Social Care Services Unit Buildings, Ty Glas, Llanishen, Cardiff, CF14 5SH Public Services – Sector Phase 1, Government 1 CORONER I am Donald Coutts-Wood,assistant coroner, for the coroner area of Leicester City and South Leicestershire 2 CORONER’S LEGAL POWERS I 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. 3 INVESTIGATION and INQUEST On 25th May 2012 I commenced an investigation into the death of Walter Gordon Powley. The investigation concluded at the end of the inquest on 4th October 2013. The conclusion of the inquest was “The cause of death was Acute Renal Failure due to Rhabdomyolisis and Metabolic Acidosis due to burns to legs. This followed Mr Powley being admitted to the Care Home and he fell against pipes. The jury considered that contributing to his death were: A lack of covering pipework, inadequate ongoing risk assessments, failure to adhere to procedures on giving and recording of medication. . 4 CIRCUMSTANCES OF THE DEATH Mr Powley died after he fell against radiator pipes underneath a radiator in his room at Western Park View Care and Nursing Home, Hinckley Road, Leicester. He fell on the 8th May 2012 having been admitted for emergency respite care on the 4th May 2012. When he fell Mr Powley’s legs were not covered. He sustained one deep burn to his right leg and numerous superficial burns to both legs. These burns were the causes of the complications that led to his death 8 days later in hospital. 5 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 1.Neither the pipes that he fell against nor the valves that connected those pipes to the radiator, were covered. HSE published guidance indicated that the maximum temperature of such pipes should be 43 degrees centigrade. Readings taken from uncovered pipes both in Mr Powley’s room and other rooms in the Home indicated that the temperatures ranged between 60 degrees centigrade and more than 70 degrees centigrade. Evidence was given at the Inquest that a number of other residential homes in this area did not have pipes and valves covered. It may well be therefore that this applies throughout the country. 2.It was therefore also apparent that there had not been a risk assessment of the physical circumstances in that room, and whether it was therefore safe for a particular resident. 3.Western Park View had been inspected by the Care Quality Commission and the Local Authority on a regular basis. Evidence indicated that these matters referred to had not been recognized by those bodies. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 29th November 2013. I, 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons 1.Western Park View Care Home; 2.the family of Mr Powley I 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. 9 4th October 2013 Signed …………………………………………….. 2
3 responses 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.
CareQuality Commission Care Quality Commission Finsbury Tower Mr Donald Coutts-Wood 103-105 Bunhill Row Coroner London The Coroner's Court, EC1Y 8TG Town Hall, Telephone: 03000 616161 Town Hall Square, Fax: 020 7448 9311 Leicester www.cqc.org.uk LE1 9BG 29 October 2013 Dear Mr Coutts-Wood, Thank you for your report into the death of Walter Gordon Powley. The circumstances in which this gentleman died were indeed sad. As you will be aware our inspectors regulate against the legislation laid down for us by the Government which is the Health and Social Care Act 2008 and subsequent regulations. In assisting providers to understand the legal requirements we produce guidance about compliance, which sets out what we would expect providers to take into consideration. In this instance this issue would fall under Regulation 15 or Outcome 10 which says: Safety and suitability of premises 15.—(1) The registered person must ensure that service users and others having access to premises where a regulated activity is carried on are protected against the risks associated with unsafe or unsuitable premises, by means of— (a) suitable design and layout; (b) appropriate measures in relation to the security of the premises; and (c) adequate maintenance and, where applicable, the proper— (i) operation of the premises, and (ii) use of any surrounding grounds, which are owned or occupied by the service provider in connection with the carrying on of the regulated activity. (2) In paragraph (1), the term “premises where a regulated activity is carried on” does not include a service user's own home. Our guidance states that the provider should also meet the requirements of the Health and Safety at Work Act 1974 and other relevant legislation. We work closely with the Health and Safety Executive (HSE) in Leicestershire with inspectors reporting any issues that they note on their inspections in nursing homes. Whilst the Commission's (CQC) compliance inspectors do look at the premises they would not necessarily have a comprehensive knowledge of the Health and Safety Act. There are a number of outcomes and regulations which can be assessed and it is rare that compliance inspectors look at them all. The inspector chooses the outcomes to assess based on the service type, the needs and vulnerability of the people using the service and any prior knowledge we hold about the service. Therefore we may not look at the pipe work unless there had been a complaint or unless it stood out to them that the area was dangerous. Our inspectors do check that radiators are covered but will often only sample a selection of people's rooms. Chairman: David Prior Chief Executive: David Behan CBE Registered office: Finsbury Tower, 103-105 Bunhill Row, London EC1Y 8TG Our local compliance inspector did inspect the location in May 2012 and reviewed seven outcomes or regulations. Unfortunately they did not inspect against Regulation 15, Outcome 10. We are currently reviewing the way in which we inspect in adult social care and are piloting a new methodology very soon. Instead of the current outcomes we will assess against five domains and ask five questions: e ls this service safe? Certainly in this circumstance the service was not safe. e Is this service effective? e Is this service caring? e ls this service responsive to people's needs? e Is this service well-led? The provider has the ultimate responsibility for ensuring that they know and monitor any unsafe conditions in the service and take the correct action. | welcome the timeliness of your report and will share its findings within my organisation; there are definitely lessons to be learnt from this very sad situation, which includes exploring the ways in which we can work more closely with the HSE and how we can ensure, within our new methodology, that our inspectors are checking high-risk areas such as this. If you would like to know more about the imminent changes in CQC, please do not j Head of Regional Compliance in Central West, or visit our website www.cac.org.uk. Yours sincerely, K David Behan Chief Executive
Awdurdod Gweithredol Health and Safety lechyd a Diogelwch Executive Cyfarwyddiaeth Gweithrediadau Operational Strategy Division Maes Donald Coutts-Wood - Coroner's Office Public Services Sector Public Services Sector A ” A i Adeiladau'r Llywodraeth G it Buildings (Phase 1 Leicester City and South Leicestershire ty Glas m oateien we The Coroner's Court archer an . Caerdydd CF14 5SH Town Hall, cia SH Eston Square, Ffon: 029 20263003 Tel: 029 20263003 if 12: LE1 9BG a Reference HSCSU/MH/Rule 43 Iiipidwers hae a0y a nin hemos — — — Date 21 November 2013 Dear Sir INQUEST INTO THE DEATH OF WALTER GORDON POWLEY — 25™ MAY 2012 - 4" OCTOBER 2013 - BURNS FROM CONTACT WITH HOT PIPES Your Regulation 28 letter dated 4" October 2013 has been passed on to me for reply as | lead for HSE'’s Health and Social Care Services Unit on the topic of social care. | was sorry to learn about the death of Walter Powley. You reported matters of concern to HSE under Schedule 5 of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. You requested consideration be given to the following: 1 — Neither the pipes or the valves in the bedroom were covered and readings taken at the Home indicated that temperatures ranged from 60 Degrees Celsius to over 70 Degrees Celsius. Evidence given suggests that pipes and valves may not be covered in other Homes in the area. 2 — There was no risk assessment of the physical circumstances of the room and whether it was safe for the resident. 3 — The Home had been inspected by CQC and the LA and the matters referred to had not been recognised. HSE has guidance on the risks from hot water and surfaces on its Health and Social Care web pages (http://www.hse.gov.uk/healthservices/scalding-burning.htm), including Information Sheet 6. Further information can also be found in HSE booklet ‘Health and safety in care homes’ (HSG220) which is available on the website and is currently being reviewed and updated. It is hoped that the revised version will be available in early Spring 2014. | totally understand your concerns but see CQC as the lead regulator and inspection body in England for health and social care providers and we believe they are better placed to proactively lead on service user safety issues. | note that you have also written to CQC. HSE has also just launched a GB Social Care Partners Forum (SCPF) which brings together regulators, care home representatives and other stakeholders. The aim of the Forum is to raise standards by producing broadly agreed guidance and disseminating it to the sector. HSE sees this as an appropriate forum to raise your concerns and it is our intention to raise the issue of assessing the risk from hot surfaces and pipe-work at the next meeting. It is hoped that the next meeting will be held in February 2014. One of the task and finish groups that has been established is looking at mapping standards and exploring how these can best be promulgated as your concerns no doubt apply to other established standards. HSE does not routinely inspect health and social care providers but does investigate serious incidents meeting our selection criteria and inspect where there is evidence of poor compliance. This may include, for example, where there is evidence of established standards, such as those concerning prevention of burns, not being followed. This is also the case for non-nursing residential care which is enforced by local authorities. | will share this letter with local authority health and safety regulators via HSE's Local Authority Unit and also arrange for the matter to be discussed at the next meeting of the national local authority practitioner forum. How health and social care is regulated across England is currently being reviewed following the Mid-Staffordshire Inquiry and this may impact on how such concerns are taken forwards in the future. | hope this addresses the concerns you have raised but please do not hesitate to contact me if you wish to discuss the matter further. Yours faithfully Senior Policy Advisor Health and Social Care Services Unit Cc _Local Authority Unit (LAU) iN)
REGISTERED NURSING TELEPHONE: 0121 451 1088 HOME AS SOCIATION urureo toy cuseantee ar prerneeecpaled JOHN HEWITT HOUSE, TUNNEL LANE, KINGS NORTON, BIRMINGHAM B30 3JN Website: wwrwrna,c0.uk Mr D Coutts-Wood Assistant Coroner Leicester City and South Town Hall Leicester LE1 9BG Me i SOUTH LEIC! } CORONERS D0} 20" December 2013, 23 DEC 2013 Re; Regulation 28 Report to prevent future deaths, RECEIVED Dear Sir, | refer to your report of 4" October 2013 concerning a Regulation 28 matter. The Registered Nursing Home Association is a trade association for owners of care homes providing nursing care (previously called nursing homes). There is no obligation placed upon home owners to join the Registered Nursing Home Association. The powers of the Association are limited to membership matters, i.e. removing membership where the standards expected of the Association are not met. Western View Care and Nursing Home is not a member of the Registered Nursing Home Association and, as such, there is nothing that | can do, of a regulatory manner, in relation to Western View Care and Nursing Home. | see that your report has also been sent to David Behan at CQC and Steve Scott at HSE, both of whom have regulatory powers which | am sure that they will now exercise as necessary. | do, however, recognise the risk which you have identified and | can report that, as an Association, we regularly advise members of their responsibility under the Health & Safety at Work Act. We particularly draw their attention to the need to ensure that the pipes leading to a radiator, as well as the radiator itself, are suitably covered to prevent the risk of burns in the event of a patient falling against the radiator. We will continue to advise members of the need for risk assessments and actions to ensure that there are safe radiator temperatures, including pipework, within the home. or QUALITY NURSING CARE in England No. 982095
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