Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0313, written 23 May 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 May 2014 |
|---|---|
| Reference | 2014-0313 |
| Deceased | Ross Boyd |
| Coroner | Tom Osborne |
| Coroner area | Milton Keynes |
| 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.
ANNEX A 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 CORONER I am Mr. Tom Osborne senior coroner, for the coroner area of Milton Keynes 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 7th November 2013 I commenced an investigation into the death of Ross Robson Boyd aged 63 The investigation concluded at the end of the inquest on 23rd May 2014 The conclusion of the inquest sitting without a jury was that the deceased died as a result of an Accident. Ross Boyd suffered a number of falls from his wheelchair whilst a resident in the Willows Care Home in Milton Keynes 4 CIRCUMSTANCES OF THE DEATH As above 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. – Ross Boyd was admitted to the Willows without an adequate assessment as to his needs being carried out with the result that he was placed at the Willows that was totally inappropriate for his needs. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you or your 1 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 by 4 July 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:- Family The Willows Care Centre Orchard House care home 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] [SIGNED BY 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.
0.8 AUG 201 oT hye | ES of of SZ ze Obs} aS “va tm Nn PRIVATE AND CONFIDENTIAL Mr Tom Osborne HM Coroner's Office Corporate Director Community Wellbeing Civic Offices Assistant Director Adult Social Care & Health 1 Saxon gate Our Ref: LS/Sw Milton Keynes MK®9 3EJ Your Ref: Reply To: Direct Line: E-mail: 5" August 2014 Dear Mr Osborne Re: Mr Ross Boyd DOB 25/06/1950 DOD 02/11/2013 | am writing following receipt of a Regulation 28 Report to Prevent Future Deaths following the inquest into the death of Mr Boyd on 23 May 2014. I have noted your concern that Mr Boyd was not adequately assessed and was inappropriately admitted to the Willows Care Centre. Having reviewed our involvement with Mr Boyd | feel it is unfortunate that his social were a was not invited to the inquest as she could have provided you with extensive information that may have been helpful in clarifying the assessment process and decision making behind the temporary placement. An assessment of Mr Boyd’s needs was conducted on 4 October 2013 by | ae a care package at home was provided; additionally there was involvement and assessment from Community Occupational Therapy, Physiotherapy and the Rapid Assessment Team (RAIT) which is part of intermediate care. The District nurses were visiting and reviewed Mr Boyd’s medication and fii visited regularly. The decision to move Mr Boyd was based on his deterioration at home and increased risks to his wellbeing which included increased difficulties with transfers and falls which, at that time, did not appear to require a hospital admission or a specific health intervention. The decision was taken in consultation with Mr Boyd, and his family and other professionals involved. Given the information available at the time of admission the move the Willows, which provides 24 hour care and support, did appear to be appropriate. did provide the Willows with a detailed support plan and reviewed the placement within 48 hours and then regularly until Mr Boyd left. It is very unfortunate that Mr Boyd continued to fall Letter050814 - TO Community Wellbeing, Civic Offices, 1 Saxon Gate East, Central Milton Keynes, MK9 3EJ Tel: (01908) 691691 Fax: (01908) 253990 when he was in the Willows however it is not apparent that this was in any way due to the type of care and support he received when staying there. Mr Boyd continued to try to transfer from his wheelchair unaided and did not use his pendant to call the care staff for assistance hence putting himself at risk of injury. In summary Mr Boyd’s placement at the Willows was made in an emergency as he was not managing at home and he, his family, and professionals involved believed a period of respite was in his best interests. Although it became apparent the Willows had difficulties meeting all of his needs | do not find that this was because of inadequate assessment prior to the placement. The Willows is a well-regarded care home and Adult Social Care use our contracted respite beds in the Centre for emergency care when required. | will ensure that managers of the social care teams discuss the use of respite beds with their teams and the need for clear assessment and support planning. Service Director Adult Social Care
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