Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0066, written 18 Feb 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Feb 2014 |
|---|---|
| Reference | 2014-0066 |
| Deceased | Jack Lynn |
| Coroner | Tony Brown |
| Coroner area | North Northumberland |
| Category | Community health care and emergency services 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.
Tony Brown LLM
H M Senior Coroner
North Northumberland
Teleph
17 Church Street
Berwick-upon-Tweed
TD15 1EE
Tel : 01289 304318
Fax : 01289 303591
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1.
NIGHTINGALES HOME HELP SERVICE
42 The Square
Kelso
Roxburghshire
TD5 7HL
1
CORONER
I am Tony Brown, senior coroner, for the coroner area of North Northumberland
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 17th October 2013 I commenced an investigation into the death of Jack Basil Lynn,
age 86 years. The investigation concluded at the end of the inquest on 14th February
2014. The conclusion of the inquest was that Jack Basil Lynn died from natural causes,
the medical cause of death being:-
1a Haemopericardium
1b Ruptured Acute Myocardial Infarction
1c Coronary Artery Thrombus
4
CIRCUMSTANCES OF THE DEATH
Jack Basil Lynn lived alone at his home address. Staff from care providers Nightingales
Home Help Service attended Mr Lynn on a daily basis morning and night, to ensure he
was prompted to take his medication and to check on his well being. A carer who visited
Mr Lynn on the 15th October 2013 for a planned 15 minute visit entered the house with a
key. The carer observed that Mr Lynn was not downstairs when she called and
assumed that he must have gone back to bed. She believed that Mr Lynn had taken his
medication for that morning by looking at a plate on a table where he normally put that
morning’s tablet, but it was probable in the circumstances that he had not taken his
medication on that day. No further checks on Mr Lynn were made by the carer at that
time to ensure his well being before she closed the door and left the property. Later that
evening the same carer returned to the property and as Mr Lynn was still not downstairs
she went upstairs to check on him. Mr Lynn was found unresponsive on the bathroom
floor. Paramedics were called but could not assist and Mr Lynn’s death was pronounced
at 20.03 hours.
5
CORONER’S CONCERNS
During the course of the inquest the evidence disclosed 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. –
Arrangements put in place for daily prompting with medication did not include keeping a
medication communication sheet at Mr Lynn’s home address as a continuous record of
his medications. This would have allowed for a more reliable check by visiting carers or
family members as it would have clearly indicated whether medications were being
taken regularly.
The absence of any check on Mr Lynn’s safety or well being during the allocated 15
minute visit on the morning of 15th October 2013 exposed Mr Lynn to potential risk,
albeit that the sudden cardiac event which occurred could not have been prevented.
The risk was present, nonetheless, and creates a risk that future deaths might occur if
action is not taken.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and/or
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 by18th April 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,
I have also sent it to the Care Inspectorate who may find it useful or of interest.
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
DATE 18th February 2014
TONY BROWN
HM Senior Coroner for North Northumberland
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.
REPORT FOLLOWING REGULATION 28: REPORT TO PREVENT FUTURE DEATHS 1. | CORONER ~ Tony Brown LLM H M Senior Coroner North Northumberland 2. | CLIENT Jack Basil Lynn 3. | MATTERS OF CONCERN RAISED BY SENIOR CORONER Arrangements put in place for daily prompting with medication did hot include keeping a medication communication sheet at Mr Lynn’s home address as a continuous record of his medications. This would have allowed for a more reliable check by visiting carers or family members as it would have clearly indicated whether medications were being taken regularly, The abserice of any check on Mr Lynn‘s safety or well being during the allocated 15 minute visit on the morning of 15°" October 2013 exposed Mr Lynn to potential risk, albeit that the sudden cardiac event which occurred could not have been prevented, The risk was present, nonetheless, and creates a risk that future deaths might occur if action is not taken. 4. | ACTION TAKEN FOLLOWING INCIDENT We will encourage all of our clients to have medication charts in their communication folder and in the case of not wishing to have one we will advise that if a carer is involved in any service concerning medication it is Company policy to have ther in the folder, We have advised all staff to make themselves re-aware of our medication policy in their handbook and to actively ask any questions that arise. We have had an independent Trainer provide a Safe Handling of Medication course in October 2013 to which twenty two staff attended. 5. | ACTION TAKEN TO EMPLOYEE INVOLVED IN INCIDENT | The staff member was given a verbal warning in a disciplinary meeting for not following Company procedure in not physically checking her client and his medication prompt and advised that in the future she should always physically check on a client unless we, Management, have their written word not to and a set procedure 's detailed for the individual client to carry out our service to their wishes. DATE 27" February 2014. DIRECTOR OF NIGHTINGALES HOME HELP SERVICE EG Favd TBSEBEBSZ TB 22:BT pTec/ea/ea
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