Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0373, written 17 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 | 17 Dec 2013 |
|---|---|
| Reference | 2013-0373 |
| Deceased | Sandra Wordingham |
| Coroner | John Woolley |
| Coroner area | Cardiff & the Vale of Glamorgan |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Director Springbank Nursing Homes, Caring Ltd 1 CORONER I am Christopher John Woolley, Assistant Coroner, for the Coroner area of Cardiff and the Vale of Glamorgan 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 31st July 2013 I commenced an investigation into the death of Sandra Wordingham. The investigation concluded at the end of the inquest on 27th November 2013. The medical cause of death was: 1A Intracerebral Haemorrhage, and the conclusion of the inquest was that the deceased died from natural causes. 4 CIRCUMSTANCES OF THE DEATH Sandra Wordingham was a resident at Springbank nursing home, College Road, Barry. She had special needs and suffered from epilepsy. On 22nd July 2013 at around 23.30 hours care assistants found her in an unconscious state. They alerted the qualified nurses who tried to rouse her without success. It was assumed that she had had an epileptic fit and needed to sleep it off. She was put to bed unconscious. At 2.00 am she was checked again and was still unconscious. She was checked at 3.30 am, 5.30 am and 7.15 am and was in the same unconscious state. At 7.15 am paramedics were called who took her to Llandough hospital. She died in hospital on 26th July 2013 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) Sandra Wordingham, was put to bed in the nursing home in an unconscious state after a suspected epileptic fit. In fact she had suffered a sudden primary intracerebral haemorrhage. No medical opinion was sought even though Sandra Wordingham remained unconscious throughout the night for a far longer period than would be expected after an epileptic fit. (2) While Sandra Wordingham suffered a profound insult which could not have been altered, had she suffered a gradual onset stroke then intervention could have been offered. In that event early medical attention would have saved her. (3) Residents in an unconscious state who are treated in future in the same way as Sandra Wordingham may be at risk of unnecessary death or injury. 1 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 11th February 2014. 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. . I have also sent it to Caring Limited who may find it useful or of interest. , Operations Manager, 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 17th December 2013 C J Woolley, Assistant Coroner 2
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.
SPRINGANK NURSING HOME
COLLEGE ROAD
BARRY
RESPONSE TO REGULATION 28 REQUIREMENT MADE BY CHRISTOPHER JOHN WOOLEY
FOLLOWING THE CORONER INVESTIGATION INTO THE DEATH OF SANDRA WORDINGHAM
RESPONDENT'S NAME & POSITION
My name (TB 10 lam the Managing Director of Springbank Care Home Limited, and the
Responsible Individual for Springbank Nursing Home.
REASON FOR RESPONSE
| have received the Regulation 28 report prepared by Christopher John Wooley, Assistant Coroner
for the Coroner for Cardiff and the Vale of Glamorgan following the investigation into the death of
Sandra Wordingham who was a resident at Springbank Nursing Home, requiring a response prior to
the 11th February 2014.
Following the investigation the Coroner expressed specific concerns in that;
Sandra Wordingham was put to bed in Springbank Nursing Home in an unconscious state by nursing
staff who suspected that she had suffered an epileptic fit, when she had actually suffered a primary
intra-cerebral haemorrhage, was unconscious state throughout the night and that no medical
attention was sought for her
Whilst Sandra Wordingham suffered a profound insult which could not have been altered, had she
suffered a gradual onset stroke, early medical attention would have saved her life.
Residents in a unconscious state who are treated in the future in the same way as Sandra
Wordingham may be at risk of unnecessary death or injury
The Regulation 28 Report has required an Action Plan to prevent the unnecessary injury or deaths to
residents who are found to be unconscious. [EEE Operations Manager (who was also the
Acting Manager at the time) andi who is now the Manager at Springbank have
assisted me by looking at the following:
1. If the core skills and knowledge to care for an unconscious person can be reasonably
expected from a professional nurse trained in a University / National Health Service setting
and registered with the Nursing & Midwifery Council
2. If the core skills and knowledge to care for an unconscious person are expected to be within
the scope of a professional nurse and be a reasonable part of the professional nurse's
periodic declaration to remain registered with the Nursing & Midwifery Council
3, Ifitis a reasonable for the Employer to expect that a professional nurse trained in a
University / National Health Service setting and registered with the Nursing & Midwifery
Council should work within the limits and scope of their training, knowledge, experience
and working within the Nursing & Midwifery Council Code.
4. How performance deficits in professional nurse's knowledge is identified and what
education & training is/should be provided to them.
When considering points 1, 2 and 3 above it is reasonable to expect that the care of an unconscious
person should be well within the capability of a professional nurse trained in a University / National
Health Service setting and registered with the Nursing & Midwifery Council
1jPage
Time & Payment for Education & Training
In my capacity as the Responsible Individual for Springbank Nursing Home | continue to provide the
necessary funding and time required for staff to train / retrain and am cognisant of the Company's
duty-of-care to ensure that staff are trained to provide care for our residents. When considering
point 4 above it is reasonable to expect the Company to provide ongoing training for all of its staff,
and the Company does provide 30 paid hours annual training for members of staff.
Types of Training
There is a growing list of mandatory training that is required by the Local Authority(s) and University
Health Board(s) in addition to list of other mandatory core training.
Training Needs
Training needs are identified in 2 ways:
1. Managers / Department Heads meet with Employees to identify education and training
needs to support / enhance clinical performance.
2. Allregistered nurses have an obligation to inform their manager of any matters that may
affect their performance and identify specific education and training needs.
Incident 19.30pm 22.07.13 until 07.30am 23.07.13
The nurses on duty from 19.30pm 22.07.13 until 07.30am 23.07.13 were
1 GN
2, RG
The Company's Reasonable Expectation of the care of Sandra Wordingham vy i
RGN and Beryl Hartland RGN
1. It is considered reasonable for the Company to expect that PO
MEE s qualified professional nurses, both of whom were trained in a University /
National Health Service setting, and both registered with the Nursing & Midwifery Council,
should have worked within the limits and scope of their training, knowledge, experience,
and to the Nursing & Midwifery Council Code.
2. The Company considers it reasonable to believe and expect that as both [x
and {J ere qualified professional nurses, who were trained in a University /
National Health Service setting and registered with the Nursing & Midwifery Council, had
been trained to a level whereby the should have recognised Sandra Wordingham’s altered
state of consciousness and irrespective of possible clinical reasons, should have assessed
and treated Sandra Wordingham appropriately, and that they should have summoned
medical assistance in a timely manner.
2|Page
The company took immediate & secondary actions to ensure the safety of current residents living in
Springbank Nursing Home
Responses Action Taken Persons Date By
: Responsible
Initial actions taken | © [J who was a nurse on the night of 23rd July
to ensure the safety 22nd July was interviewed and suspended from duty Operations 2013
of residents Manager &
Acting Manager
at Springbank
Nursing Home
Secondary Actions e who was a nurse on duty on the night of 23.07.13
taken to ensure the 22nd July was interviewed and, at a later point Operations
safety of residents suspended from duty Manager &
(Following Acting Manager
investigation by at Springbank
South Wales Police Nursing Home
& Safeguarding)
e The company required to attend 31.12.13
disciplinary procedures for gross misconduct. She was Responsible
dismissed from her position as a qualified nurse and a__| Individual for
copy of the hearing notes and outcome was provided to | Springbank
the Nursing & Midwifery Council Nursing Home
e The company required [EERO attend This will
disciplinary procedures for gross misconduct. The Responsible be
process is ongoing. When this is concluded a copy of Individual for concluded
the hearing notes and the decision / outcome will be Springbank as soon as
forwarded to the Nursing & Midwifery Council Nursing Home | possible
REGULATION 28 ACTION PLAN
Item Action Taken Persons Date By
Responsible
Improved First Aid & | All staff to attend training with specific training element Planned
Life Support for the immediate care of the unconscious person Operations for March
Training Manager 2014.
Springbank
&
Manager
Ensuring Nursing Following training and instruction nurses will have an Planned
Staff Competency assessment of their competency to; Operations for March
e recognise consciousness levels Manager 2014 as
e undertake appropriate life support and neurological Springbank part of 1*
observations & Aid
e record & document life support and neurological Training
3| Page
observations & Aid
record & document life support and neurological Training
observations P|
be aware of a DNNAR arrangement with the agreement
of the resident / relative, and signed by the resident's Manager
GP not to actively seek emergency assistance when the
resident may be dying.
assure their line-manager that they will comply with
training & guidance
Adherence to All nurses have been provided with a copy ofthe NVC | [J [5°
Nursing & Midwifery code Operations February
Council Codes All nurses have been reminded to practice within their | Manager 2014
levels of training, competency, knowledge and Springbank &
experience & 41°
All nurses have been reminded of their obligation for P| February
public protection 2014
All nurses have been reminded of their obligation to Manager
maintain their knowledge and skills through PREP
Summoning All staff have been instructed to summon emergency 6"
Emergency services to attend to all unconscious residents as Operations February
Assistance quickly as possible Manager 2014
Where a valid DNNAR is in place the nurse MUST follow | Springbank
the GP's instruction(s) & a1"
If Emergency Service Staff attend they must be shown P| February
the valid DNNAR 2014
Where there is doubt about the level or recovery of Manager
consciousness nurses MUST err on safety and summon
the Emergency Services
A protocol has been produced and made available to all
staff working at Springbank Nursing Home
Knowledge of The risk assessments and care plans will contain PY Care Plan
probable reasons accurate and specific information about the possible or | Operations Audits for
and causes for probable causes and reasons why a specific resident Manager Epilepsy
residents who may may become unconsciousness. Springbank and
become unconscious Risk Assessment and Care Plan for epilepsy must & Diabetes
due to epilepsy (and contain details of the type of fits that the person may | | are
other illnesses) have (e.g. grand mal, petite mal, partial incomplete available
seizures etc, and whether the person has a prolonged Manager to tackle
post-seizure recovery period) this.
Providing & Sharing The protocol for managing the unconscious person has 6th
Information about been provided for all “occasional staff" and is included | Operations February
the management of in the Agency Nurse Induction form Manager. 2014
unconscious people The Nurse Agencies will be informed and a copy of the | Springbank
with Bank and protocol will be provided to their head offices &
Agency Nurses
working occasional
shifts Manager
4|Page
In the event of
failure to summon
timely medical
assistance
The member of staff will be required to explain their
action/ inaction
The member of staff will be reported to the
Safeguarding Team. This may lead to a criminal
investigation and prosecution
The member of staff will be suspended from duty and
disciplined. This may lead to dismissal and referral to
the Nursing & Midwifery Council
Operations
Manager
Springbank
&
Manager
immediate
& Ongoing
Signature
Position: Responsible Individual, Springbank Nursing Home
5] Page
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