Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0229, written 28 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 | 28 Feb 2014 |
|---|---|
| Reference | 2014-0229 |
| Deceased | Peter Norman Nott |
| Coroner | Nicholas Graham |
| Coroner area | Oxfordshire |
| Category | Care Home Health 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 Inquest into the death of Peter Norman NOTT THIS REPORT IS BEING SENT TO: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Rush Court Nursing Home, Shillingford Road, Wallingford, OXON CORONER | am Nicholas Graham, Assistant Coroner, for the Coroner area of Oxfordshire 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 9 September 2013 an investigation commenced into the death of Peter Norman Nott, | who was 75 years old. The investigation concluded at the end of the inquest on 26 February 2014. A short form conclusion of accidental death was recorded. Dr Norman Nott had fallen in his room at Rush Court Nursing Home causing injury to his head. The fall occurred around 10:30 hours but he was not taken to the hospital until 18:57 hours that evening. He succumbed on 8 September 2013. The medical cause of death was recorded as: 1(a} Subdural haemorrhage 1(b) Parkinson’s disease | 4 CIRCUMSTANCES OF THE DEATH 41. Dr Peter Norman Nott had a complex medical history of Parkinson's decease with Shy-Drager syndrome (severe postural hypertension) with Dementia. He was assessed as being at very high risk of falls. 2. Although the nursing home had undertaken detailed assessments to address Dr Norman Notts propensity for failing, there were numerous incidents of falls at the home. 3. As indicated, on the morning of 2 September 2013 Dr Norman Natt experienced an unwitnessed fall in his room at the nursing home. He was attended by nursing home staff and was conscious. He spent the next two hours lying down (which was not uncommon) until he was hoisted onto the bed where he remained and was nursed and regularly checked. Also the GP was called and suggested that he be closely monitored. 4. At 17:45 hours his condition deteriorated and an ambulance was called which took him te hospital at 18:57 hours 5. The hospital took a CT scan and in view of his condition considered that surgical intervention was futile. fo He sadly passed away on 8 September 2013 at 20:00 hours. CORONER'S CONCERNS During the course of the Inquest the evidence revealed matters giving rise to concerns. in my opinion there was a risk that future deaths would occur unléss action is taken. in the circumstances it is my statutory to report to you the matters of concern as follows 1. Although staff at the care home were attentive to Dr Norman Nott after his fall, and advice was sought from Dr Norman Notts GP, it was accepted in questioning that the trained staff should have undertaken neuroiogical observations over and above a simple visual examination. The need to undertake further examination was heightened when the length of time Dr Norman Nott remained lying down (although conscious) and certainly as this time extended into the afternoon. 1 recommend that Rush Court Nursing Home review their procedures for attending on a patient after a fall (whether conscious or not) in order to identify the appropriate level of examination and nursing attention required. 2. When Dr Norman Nott arrived at hospital the Emergency department undertook a CT scan and the evidence from the Consultant Geratoiogist and Acute Physician was that due to the degree of brain injury and the fact that Dr Norman Nott had been “deeply unconscious from the beginning” earlier attendance at hospital would have not made any difference to the outcome. The doctors conclusion that Dr Norman Nott had been unconscious was information obtained from the paramedics attending at the nursing home who had gleaned the information that he was unconscious from the staff. The evidence that Dr Norman Nott was unconscious was incorrect. This information should have been passed on accurately. My recommendation is that the Rush Court Nursing Home review the information they provide to paramedics attending and the procedures in place fo ensure the accuracy of the information can be passed to paramedical staff attending at the home. | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your | organisation has 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 the Thursday 24 April 2014. 1, 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: }am also under a duty to send the Chief Coroner a copy of your response bo 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. Dated: 28 February 2014 Nicholas Graham, 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.
Exceptional care for the individual
ELIZABETH FINN HOMES LIMITED
Hythe House, 200 Shepherds Bush Road, London W6 7NL Tel: 020 8834 9200 Fax: 020 8834 9299
OXFORDSHIRE
CORONERS OFFICE
16 MAY 2014
RECEIVED... n.essscsscessessser sega Le
Mr N Graham
Assistant HM Coroner for Oxfordshire
Oxfordshire District Register Office
2” Floor, 1 Tidmarsh Lane elizabeth finn
Oxford homes
OX1 1NS
19 March 2014
Dear Mr Graham,
| write in response to your report dated 28" February 2014, regarding the
circumstances surrounding the death of Dr Peter Nott, a resident at Rush Court care
home.
The report highlights some concerns that were discussed at the inquest and the
organisation’s duty to respond with an improvement plan within the timescale set.
For clarity { will deal with each point raised in turn.
Concern One: |! recommend that Rush Court Nursing Home review their
procedures for attending on a patient after a fall (whether conscious or not) in
order to identify the appropriate level of examination and nursing attention
required.
The organisation has reviewed its polices and procedures when dealing with a
resident who has experienced an unwitnessed fall. This procedure will be cascaded
to all clinical staff with instructions that should a resident fall and it is unwitnessed,
then nursing staff or the person in charge of a residential home, should commence
neurological observations. These will be recorded using the Glasgow Coma Scale
and incorporated into a resident’s care plan.
This procedure will be reinforced during staff meetings and any individual training
needs will be monitored through the supervision, learning and development
programme. Basic competencies for head injury care will be reviewed with all
clinical staff and the person in charge of our residential home.
The timescale for this action to be completed is 1st April 2074.
Concern Two: Rush Court Nursing Home review the information they provide
to paramedics attending and the procedures in place to ensure the accuracy of
the information can be passed to paramedical staff attending the home.
Procedures have been reviewed with reference to information given to paramedics
attending the home. The procedure states that only a Registered Nurse or person in
charge of the home must hand over clinical information to the paramedic team. This
is to be clear and concise, detailing observations and clinical judgement where
appropriate. This will then be recorded clearly in the resident's care plan for future
Registered in England and Wales, Number: 5225008 enquiries@efhl.co.uk = www.ethl.co.uk Organisation
reference. This information will be given to staff during staff meetings and all staff
will sign as per policy to confirm they have agreed to and understood the procedure.
The timescale for this action to be completed is 1st April 2014.
Elizabeth Finn Homes strives to offer quality clinical care to all of our residents and
to review policies and procedures on an annual basis to ensure best practice is
maintained.
We have welcomed your advice upon how to further improve our policies and
procedures and hope that this action will help to improve our practice.
Yours sincerely
Head of Care Operations
Elizabeth Finn Homes Limited
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