Annie Jones

Abbey Dale House

“Caring beyond Excellence”

61 Prince’s Drive Tel: (01492) 530955
COLWYN BAY 2

Conwy Borough

LL29 8PW Web: www.adhcare.co.uk

6" January, 2014

H.M. Coroner

H.M. Coroner's Office
County Hall
Wynnstay Road
RUTHIN

LL115 1YN

For the attention of Mr. John A Gittins
H.M. Coroner

Dear Sirs

Re: Inquest of Annie Ceinwen Jones - 25th September, 2013

| acknowledge receipt of your letter of 20th November, together with
the Regulation 28 Report, and | enclose my response.

| trust that this is self-explanatory, but please do not hesitate in
contacting me if you require any clarification.

Yours sincerely,

Registered Manager/Proprietor
Abbey Dale House

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Coroners (Investigations) Regulation 28:
Report to Prevent Future Deaths

In response to the Report dated 20th November, in relation to Annie
Ceinwen Jones.

| will respond to the four matters of concern highlighted in the report, and
advise of actions taken where appropriate. There are some areas of the
report which | feel need some clarification.

In the report in section 4, which states "...with extensive bruising
sustained in a fall from a "stand aid" ..... | wish to clarify that Mrs Jones
did not suffer a "fall" as such, but slipped down the sling, which held her,
and prevented her from falling to the floor. The sling which was used
with the stand-aid has a strap across the chest area, which caused the
bruising to her upper body, which was identified across her chest.
Because of her medication, (prednisolone), this exaccerbated her
bruising, a common side-effect of this medication.

In section 5, your report stated that Mrs Jones had not been weight-
bearing for over three years. | believe that there has been some mis-
understanding about this term. Mrs Jones had not been able to walk
since she had been with us (since 23rd June 2010), but she was able to
partially weight-bear - sufficiently to transfer with a stand-aid.

Stand-aid hoists can be used on residents to provide a quick and safe
transfer from any sitting to standing position, and vice versa. To be able
to use a stand-aid, resident's should be able to 'weight-bear' to a
certain extent through their knees, and have sufficient upper body
muscle strength/sitting balance.

Mrs Jones was assessed to use the Pallas Stand-aid by J

GS & Registered General Nurse in March 2012, and she had
successfully used this equipment ever since then when using the toilet.
In fact, she had used this equipment to go from her chair to the
wheelchair, and from her wheelchair onto the toilet immediately prior to
this incident which resulted in the bruising, which occurred when she
was coming off the toilet, to go back into her wheelchair.

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Specific Matters of Concern

{

An inadequate assessment of the mobility of Mrs Jones.

Mrs Jones was assessed by iE! together with I
WB in March, 2012.

We acknowledge that the paperwork accompanying the risk
assessment was not as comprehensive or as legible as it could
have been, and we have taken steps to overcome these issues.

Following this event, and to improve the provision of manual
handling training within Abbey Dale House, | undertook a 4-day
specialised Train-the-trainer course in February 2012, run by Edge
Services, a national company that specialise in Manual Handling
Training. This course also involved a risk assessment element to
the course, to enable full manual handling and person handling
risk assessments to be performed by myself.

The stand-aid was unsafe for use with Mrs Jones

Mrs Jones had successfully used this particular equipment since
the original assessment in March 2012, and the manual handling
plan was formally reviewed monthly. On each occasion that any
resident is transferred with equipment, the staff have to assess
their ability to follow instructions; and to also assess their physical
capabilities, which can vary from day-to-day, and even from hour-
to-hour.

On this particular day, Mrs Jones had transferred twice using the
stand-aid before the incident that caused the bruising. On this
occasion, for some unknown reason, Mrs Jones became agitated
and released her grip on the stand-aid, resulting in her sliding
slightly downwards until held by the strap across her chest.

Page 2 of 3

3 Not all staff were aware of the limitations of Mrs Jones with regard
to her mobility.

In order to overcome any communication issues with regards to
manual-handling changes, and to provide a point of reference for
all staff (including new/agency staff), an updated document has
been created to provide a snapshot of each resident's needs,
which includes a summary person handling plan, which is readily
available to all care staff.

4 Not all staff were able to operate the stand-aid safely.

All of our staff are trained in the use of the manual handling
equipment available within the home, however, this may not
always be fully and comprehensibly documented.

In order to improve this, Abbey Dale House has adopted the
All-Wales Manual Handling Passport, which is an intensive
manual-handling training programme and includes person
handling modules.

The improved documentation will include sections for staff and
assessor to sign off that they are competent using each piece of
manual handling equipment.

| believe that the actions that we took immediately after this unfortunate
incident with Mrs Jones, and the subsequent improvements to the
manual handling operations within the care home, through improved
training and documentation, will reduce the likelihood of further incidents
of this nature, and subsequently improve the wellbeing and dignity of our
residents.

Registered Manager / Proprietor
Abbey Dale House

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