Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0330, written 6 Dec 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 Dec 2013 |
|---|---|
| Reference | 2013-0330 |
| Deceased | Keith Barton |
| Coroner | Patricia Harding |
| Coroner area | Mid Kent and Medway |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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ANNEX A 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. Ashley Gardens Nursing Home | 1 | CORONER | am Patricia Harding, senior coroner for the coroner area of Mid Kent and Medway 2 | 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. 3 | INVESTIGATION and INQUEST On the 3 December 2013 | commenced an investigation into the death of Keith Barton, 77 years. The investigation concluded at the end of the inquest on the 4"" December 2013. The conclusion of the inquest was that Keith Barton died as the result of an accident, the medical cause of death being ‘a. Inhalation of food II Dementia. Box 3 was completed that Keith Barton suffered from Alzheimer’s disease and dementia. He had a history of pocketing food and not swallowing and was therefore at a risk of choking. He was assessed by a speech and language therapist as requiring supervision and monitoring whilst eating. At the nursing home supervision was by way of periodic check. On the morning of the 5" February 2013 he choked and died whilst eating his breakfast in his room on his own. There is no evidence that he was checked while eating his breakfast 4 | CIRCUMSTANCES OF THE DEATH Keith Barton had a history of Alzheimers disease and dementia and as a result had a history of pocketing food and not swallowing. He was therefore at risk of choking. Whilst resident at Ashley Gardens nursing home he had been assessed by a speech and language therapist (SALT) as requiring supervision and monitoring while eating. It was not clear whether this was communicated at the time of the assessment but was confirmed in writing at a later date. This was interpreted by staff at the nursing home as intermittent rather than constant supervision and when eating breakfast in his room he was subject to periodic checks. The majority of meals were taken in a communal area. There were 3 previous documented choking incidents prior to Mr. Barton’s death, on each occasion staff were on hand to assist and no harm occurred. On the 5" February 2013 Keith Barton was eating breakfast in his room when he choked and died. There was no evidence that Mr. Barton had been checked whilst eating his breakfast by any of the staff on duty. The SALT gave evidence at the inquest that by supervision and monitoring she meant constant supervision by someone sitting with him or in close proximity. The nursing home did not ask for clarification of the recommendations communicated in the letter from the SALT which was somewhat ambiguous. 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) That clarification as to the level of supervision and monitoring was not sought from the speech and language therapist in a case where the recommendation required clarification (2) That external training in relation to dysphagia awareness which had been put in place following the death of Mr. Barton could not be delivered to all staff members because of constraints on the number of places available (which could potentially be resolved by in-house training) (3) That incident reports were not completed and therefore a further SALT review had not been triggered (this has been addressed by the nursing home and does not require further action to be taken) (4) That residents at risk of choking were subject to periodic checks (this has been addressed by the nursing home and does not require further action to be taken) ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths (in respect of (1) and (2) above) 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 31 January 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. 1 COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested | have also sent it the Speech and Language Therapy Team at Kent Community Health NHS Trust who may find it useful or of interest. | 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. 6" December 2013 Pay |
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.
1U-TIHR-e14 WSIDy From: lo? 3624 rse34o194 Pase:274
7 March 2014
Coraner P Harding
Senior Coroner Mid Kent and Medway
Kent Register Office
The Archbishop's Palace
Palace Gardens, Mill Street
Dear Senior Coroner Harding
(am wetting in response to| your Prevention of Future Deaths Report folowing the inquest touching on
the death of Mr Keith Barton,
First, | would like to again express my sincere condolences to the family and friends of Mr Barton.
|
Your report raises four matters of concern, namely:
ts Clarification of recommendations from the Speech and Language Therapist (SAI.T).
2. Delivery of training in relation to dysphagia awareness.
3. Completion of incident reports.
4. The process for checking residents at risk of choking.
Your report confirms that you were Satisfied, at the conclusion of the inquest, that Ashley Gardens had
put in place appropriate measures in relation to items 3 and 4 and that no additional action needs to
be taken to address thése concerns,
1 deal with your remaining concems helow:
1. Jarification of recommendations from SALT
Mr Barton had a diagnosis’ of Picks disease, As a result of his condition he had a history of pocketing
food and not swallowing. Whilst at Ashley Gardens he was assessed as being at risk of choking
because of his condition and he was seen by SALT on 23 August 2012. The written referral received
"from SALT confirmed that Mr Barton required supervision and monitoring whilst eating. In accordance
with usual practice at Ashley Gardens this was interpreted as meaning period checks rather than
constant supervision, —
The evidence at the inquest was that no member of staff fram the home had checked on Mr Barton
whilst he was eating breakfast on the morning of S February 2013, The SALT therapist gave evidence
Stating that the written recommendation sent to Ashley Gardens on 16" October 2012 meant constant
supetvigion by someone sitting with Mr Barton or in close proximity. This was not Ashley Gardens'
understanding of the recommendation made.
Whilst it is accepted that no clarification was sought from the SALT in relation to the recommendation,
| would have expected 'the wording of the recommendation ta bé specific and clear if it was their view
that constant supervision was required.
LIFE STYLE CARE (2011) PLC :
REGENT HOUSE, |
THEOBALD STREET, ELSTREE, ‘
BOREHAMWOOD, HERTS. WD6 485
TRL: (020) 8327 1330
FAX: (020) 8327 134D
Email: admin@lifestylecare.co.uk
Website: www.lifestylecare.co.uk
Registered No. 7709654
{ met with SALT on 17 January 2014 in order to discuss your concems in respect of the ambiguity of
their recommendation In this case. The following action plan has been agreed:
(a) We will ensure that all SALT recommendations are seen by the senior nurse on duty so that a
senior member of staff can|determine whether any clarification is required
(b) SALT will ensure that where supervision is recommended appropriate detail of the expected
supervision is given
2. Delivery of training in relation to dysphagia awaranass
Ashley Gardens have requested training from SALT hawever they have confirmed that only 2
members of staff from Ashley Gardens are permitted to attend each training session. Ashley Gardens
have offered to host the SALT training however they have been informed that they are stilt only
permitted to have 2 members of staff. Unfortunately the result is that it would take a significant period
of time for all members.of staff to receive dysphagia awareness training.
1 met with SALT on 17 January 2014 in order to discuss your concerns in respect of the delivery of
training in relation to dysphagia awareness. | was informed that SALT was in the process of agreeing
the content of future dysphagia training for nursing home staff. This was so that they can have the
training validated by the Trust to ensure the cantent and quality is of a high and consistent standard
across the whole Trust'area,
SALT confirmed to me that this process would be completed by the end of February 2014 so that
training could start being offered again from March 2014.
As a result of the above | sourced some dysphagia awareness training from a private SALT therapist,
She has experience of delivering dysphagia training to difference healthcare professions across
nursing homes, day centres and hospitals. Her training is based on literature, published research and
her own experience in the sector. She has over 12 years of clinical experience as a speech and
language therapist and Is now an independent practitioner. She is registered with The Royal College
of Speech and Language Therapists and Healthcare and Professions Council.
The sessions she provides run for 60 minutes and cover the following topics:
The normal swallow,
What can go wrong;
* Signs and symptoms of dysphagia:
e Howdifficulties are assessed;
e Treating and compensating for dysphagia
H
The sessions are interactive with practical exercises and a short video clip. The session can be given
to up to 20 people at one time.
‘LIFE STYLE CARE (2012) PLC ; .
REGENT HOUSE, Page 2 of 3
THEOBALD STREET, ELSTREE, i
BOREHAMWOOD, HERTS, WD6 4S
TRL: (020) 8927 1330 :
FAX: (020) 8327 1340 :
Email: arlmin@lifestylecare.co.uk
Website: www.llfestylecare.co.uk
Registered No, 7709694
ae mes Lee) Ber Om 1 Ue loi secu rostb1lse have:4-4
| booked a session which Was completed on 15” February 2014 for 15 members of staff and another
session has been arranged for 17” March 2014 which will be attended by 20 members of staff.
| also booked a Nutrition and Hydration course which was completed by 15 members of staff on 5”
March 2014. This was 4 more generic training covering feeding. | do not intend book any future
sessions of this training as|it was not as beneficial as the dysphagia training.
| received a response ffom|SALT on 6” March 2014 which confirmed they will now be charging £125
per session and sessions gan be booked from the end of March. | was given verbal confirmation trom
the SALT Manager that this will be a course just run for Ashley Gardens and we can have
approximately 10 to 15 members of staff on each session. However, | was informed that this is subject
to written confirmation.
Should there prove to be any issues causing delays in the completion of the SALT training ! will book
more sessions with the-above private SALT therapist in order to ensure that the training of staff is
completed as quickly as possible.
Please let me know if! gar be of any further assistance.
Yours sincerely
Home Manager
Ashley Gardens Care Centre
LIFE STYLE CARE (2011) PLC
REGENT HOUSE,
THEOBALD STREET, SLSTREE, Peans ots
BOREHAMWOOD, HERTS WD6 48S
TEL: (U20) 8327 1330 : DIRECTORS
FAX; (U20) 8327 1340 RG. SACHDEY, FCCA, AMBIM
Email: admin @litesrylecare.co.uk : EE.2 WARE, MA, MPHTL,
‘Website: wwwlifestylecare.couk H DAPENNEY, FCIFD
Registered No. 770964 J.BASKARAN, BCCA
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