Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0130, written 21 Mar 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Mar 2014 |
|---|---|
| Reference | 2014-0130 |
| Deceased | Derrick Plater |
| Coroner | David Osborne |
| Coroner area | Norfolk |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. 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. BEE = xecutive Director, Children, Families and Adults Services, Cambridgeshire County Council, Older People's Services, Hereward Hall, County Road, March, Cambs PE15 8NE CORONER tam DAVID OSBORNE, assistant coroner, for the coroner area of NORFOLK 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. y | INVESTIGATION and INQUEST On 10 June 201 1an investigation was commenced into the death of DERRICK ARTHUR PLATER, AGED 85. The investigation concluded at the end of the inquest on 10 March 2014. The conclusion of the inquest was as per the attached narrative conclusion. The medical cause of death was, inter alia: 1a Septicaemia and 1b Unstageable sacral pressure sores. CIRCUMSTANCES OF THE DEATH The circumstances of Mr Plater’s death were that he was a resident at Goodwins Hall in King's Lynn, Norfolk, a Hallmark Care Homes nursing home. On 1 May 2011 he was admitted to hospital and returned the same day with a pressure sore. The pressure sore did not respond to:treatment and he was readmitted by his GP to hospital on 25 May 2011. His condition continued to deteriorate and he died on 7 June 2011. Mr Plater had been placed at Goodwins Hall following an assessment by the local authority. 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. — | was told that it was not at the time normal practice to undertake a visit of the care home being considered for placement, notwithstanding that Mr Plater had complex needs - having undergone a laryngectomy and had a stoma. Accordingly there was a total teliance upon assurances given by the care home in‘considering whether it could in fact meet the assessed needs. It was indicated that if similar circumstances arose today it is likely that a visit would be undertaken. However the witness was unable to confirm whether there were guidelines or protocols for when a visit should be undertaken as part of the assessment and placing process. . | am therefore concerned that: 1. if there are guidelines and/or protocols for when a visit of care home should be considered and/or undertaken as part of the assessment and placement process there may need to be a review of the dissemination and awareness of any such guidelines and/or protocols 2. If there are no such guidelines and/or protocols there may need to be a review as to whether such should be drawn up ACTION SHOULD BE TAKEN \ In my opinion action should be taken to prevent future deaths and | believe you and your organisation 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 Friday 16 May 2014 |, 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons : Derek Winter (Archivist) HM Coroner for the City of Sunderland Civic Centre Burdon Road Sunderland SR2 7DN | 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 tesponse, about the release or the publication of your response by the Chief Coroner. 21/03/2014 VP Moe — 5 ay . David Osborne - Assistant Coroner
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.
My ref: Your Date: Conta Direct E Mail: AB P0S/, "%, C) foo e 2s Op Saye Chief Exec ALG Abrdr | Cambridgeshire taMay 2014 VEOH PARA County Council Vai MAY 2014 - ‘TT ne / Children, Families and Adults Services Mr D Osbourne -~. Executive Director: Adrian Loades Assistant Coroner Box No: CC1001 Norfolk Coroner's Service ox “Shire Hall 69 — 75 Thorpe Road Castle Hill Norwich Cambridge Norfolk CB3 O0AP NR1 1UA Fax: 01223 475937 Dear Mr Osbourne Re: Derrick Arthur PLATER (deceased) Response to Regulation 28 report concerning the death of Mr D A Plater Thank you for your ietter dated 24 March 2014 requesting a response to a Regulation 28 Report. Please accept this letter as that response pursuant to Regulation 29 of the Coroners (Investigations) Regulations 2013. In your report you were concerned that there was a total reliance upon assurances given by the care home, Goodwins Hall, that it could meet Mr Plater’s needs. At the Inquest into Mr Plater’s death, HS Cambridgeshire County Council's witness, tried to explain that under the terms of the care home’s registration with the Care Quality Commission the Registered Manager, in each home, is responsible for determining whether the assessed needs can be met in their care home. The decision to accept the placement by the care home is based on the health and social care assessments provided to the home. That decision is usually supported by staff from the home visiting the person in hospital to complete their own assessment before making a decision to accept the placement. ME ¢xplained that the social worker completed a comprehensive assessment of Mr Plater’s social care needs to enable the home to reach their decision. Hospital staff were responsible for completing the assessment of Mr Plater’s on- going health needs. The social worker sought reassurance from the multi- disciplinary team in the hospital that they were confident that the home could meet these needs. Discussions took place between ward staff and staff from the home and the senior nurse from the hospital team confirmed to the social worker that she Osa YS Printed on recyete paper utive: Mark Lloyd www.cambridgeshire. gov. uk felt that the needs arising from Mr Plater’s laryngectomy and stoma could be met at Goodwins Hall. a cid that the social worker was aware that staff from the home had carried out their own assessment of Mr Plater’s needs by visiting him in hospital prior to accepting his placement. As a consequence of repeated questioning on the discharge planning and placement process and the stress of attending the Inquest, EEEIndicated that if similar circumstances arose today it is likely that a visit by a social worker would be undertaken before the placement was made. On reftection JIIEEEEEEEErecognises that this response was not correct. [i WEEE sincerely regrets that she was unable to clearly explain to you the Registered Manager's responsibilities at the care home and assure you that the social worker had fully carried out their duties to enable the home to make an informed decision. a also apologises for indicating that a visit would be undertaken in future. In Mr Platter’s case, where there were complex health and social care needs, a visit to the home by a social worker would not, in my opinion, have provided any added assurance because social workers are not professionally competent to make judgements on whether Mr Plater’s health needs were likely to be met at Goodwins Hall. Therefore, | believe that it is unlikely that a pre-placement visit in these circumstances would help to prevent future deaths in similar circumstances. For the reasons presented above a pre-placement visit by a social worker is not and will not be part of the assessment and placement process and there are no plans to introduce this step. | am not aware of any Local Authority that routinely undertakes a pre- placement visit in these circumstances. However, please be assured that if we had received information, from any source, that Mr Plater’s needs were not being met this would have been investigated immediately and steps taken to ensure that his needs were met at Goodwins Hall or arrangements made to transfer him to another home. Yours sincerely Nae Coe Adrian Loades Executive Director: Children, Families and Adults Services AB 2057, % C} eo C_) as £0, Xe ¥ ES Pentel en eqciad pacer Save Chief Executive: Mark Lloyd www.cambridgeshire. gov. uk
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