Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0167, written 14 Apr 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Apr 2014 |
|---|---|
| Reference | 2014-0167 |
| Deceased | Winifred Dennis |
| Coroner | Rebecca Cobb |
| Coroner area | North East Kent |
| Category | Community health care and emergency services related deaths |
| Organisation named | Kent Community Health NHS Foundation Trust |
| 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.
COP
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
| The Chief Executive, Kent Community Health NHS Trust _
CORONER
lam Rebecca Margaret COBB, Senior Coroner for the Coroner area of North-East Kent
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.
a
CIRCUMSTANCES OF THE DEATH
INVESTIGATION and INQUEST
On 25" July 2013, | commenced an investigation into the death of Winifred Olive
DENNIS. The investigation concluded at the end of the inquest on 22" January 2014.
The conclusion of the inquest was a Narrative (as set out in box 4 below), the clinical
cause of death being: .
ta. Bronchopneumonia, Deep sacral pressure sore.
2. Coronary atheroma, Diabetes mellitus.
Mrs. DENNIS died on 27'" December 2012 at her home address of St Alban’s House,
12 The Grove, Deal, Kent following a slow deterioration in her health leading to reduced,
and ultimately no, mobility. The sacral pressure sore started on around 19" September
2012, initiated by a scratch as a result of an infection she was suffering from. During her
time at St Alban’s, from the end of July 21012 up to the time of her death, she was
regularly seen by community nurses, podiatrists and general practitioners and had a
pressure-relieving mattress, an air cushion for sitting on and, from early September, heel
protectors, but not an airflow mattress that she had had at the previous Home. No
indication was given by anyone to the Residential Home that such a mattress would be
appropriate, until December when she was too poorly to be moved.
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) The evidence was that within Kent Community Health NHS Trust the community
nurses are organised into teams dependent upon the GP surgeries that they are
covering. As a result, the moving of a patient from her own home to a Care Home, or
between Care Homes, can cause her to be transferred from one Community Nursing
Team to another, as occurred in this instance. Although the patient's notes would
transfer, the Trust had no formal handover document as such for a patient in these
circumstances and, in this instance, the information that at her previous Home she had
had the benefit of an airflow mattress was not communicated to the next Home on her
move there. Care Homes look to the community nurses for such guidance.
(2) In other cases, similar important information not directly of a clinical nature might not
be transferred and the chances of optimum care being delivered to a patient might
accordingly be reduced.
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 9'" June 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
Person rT | have also sent it to The Chief Executive, Care
Quality Commission.
! 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.
44" April 2074
mn Rehecta CoN,
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.
Kent Community Health NHS NHS Trust Our ref: CORO013 Legal Services Department Your ref: RC/MAB/MIC/T Trinity House 110 - 120 Upper Pemberton Date: 6 June 2014 Eureka Business Park Ashford PRIVATE & CONFIDENTIAL Kent TN25 4AZ Rebecca Cobb HM Senior Coroner North East Kent Area 5 Lloyd Road Broadstairs Kent Email: CT10 1HX Dear Ma'am Resumed Inquest touching the death of Winifred Olive Dennis | write further to your correspondence dated 14 April 2014, which encloses a copy of the Regulation 28 letter. Firstly, | would to take the opportunity to thank you for bringing this-matter to my attention. | have conducted a full internal review of the care afforded to Ms Dennis by the Community Nursing Teams across Kent Community Health Care Trust. | can confirm that as a result of the investigation, an action plan has been implemented into practice, to target and address your concerns. Concerns Raised These concerns were in relation to the lack of a formal handover process between our Community Nursing Teams. The Trust recognises that structured handover processes are vital in order to deliver a co-ordinated level of care that meets patient’s on-going needs in the community. Response A formal process to enable the transfer of care between community nursing teams has been devised. A working group has been established to revise the policies and procedures and monitor through clinical audit all aspects of transfer of care. Work is already underway to improve the documentation associated with transfer to ensure all patients have a full holistic reassessment prior to transfer that clearly documents the patients care needs handed over to the teams responsible for implementing the on-going care. This process ensures continuity of care. Patients’ on-going needs are clearly identified and communicated effectively upon transfer between community nursing teams. The training available to staff for holistic assessment and care planning has been revised and the new programme is now being rolled out. | am confident that this will enable our Community Nursing Teams to deliver a high level of quality care, which is patient focussed. The implementation of these actions will be regularly monitored through the Trust's committee structures. The Trust will be making contact with the family of Ms Dennis, to go through the details of our internal investigation. 1am grateful for the opportunity to review and improve our service and thank you once again for highlighting these issues to me. Yours faithfully Marion Dinwoodie Chief Executive
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