Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0339, written 4 Jul 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Jul 2014 |
|---|---|
| Reference | 2014-0339 |
| Deceased | Stanley Bere |
| Coroner | Penelope Schofield |
| Coroner area | West Sussex |
| 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 (1)
NOTE: This form is to be used after an inquest.
THIS REPORT IS BEING SENT TO:
1. The Salvation Army
2. The Manager, Villa Adastra Care Home
1 | CORONER
| am Penelope Schofield, Senior Coroner for the coroner area of West Sussex
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 29 April 2014 | held and concluded an inquest (and investigation) into the death of
Stanley Bere, aged 89 years old. The formal conclusion was that Stanley Bere, died on
4" June 2012 from congestive cardiac failure and bronchopneumonia. He had been
immobile for some time following an assisted fall on 31% October 2011, some 8 months
earlier, in which he suffered a fractured ankle. This fractured ankle together with the
subsequent infection contributed to his death.
4 | CIRCUMSTANCES OF THE DEATH
Mr Bere had been a resident of the Villa Adastra nursing home since December 2009.
He had during that time suffered a number of falls. On 31% October 2011 he had
another fall. An incident report was completed where it was noted that he had suffered
no injuries. The fall was not recorded at the time on the home’s Cardex system. Mr
Bere had in fact sustained a serious injury in the fall to his ankle. It then appeared that
there were many missed opportunities by the staff at the home to spot these injuries..
The family raised concerns on a number of occasions but it was not until 8" November
2011 that action was taken and the true extent of Mr Bere’s injury was discovered. His
ankle had been fractured in two places which was required to be pinned in the Hospital.
After this procedure he returned back to the Care Home. A few weeks later the District
nurse realised that one of the implanted screws was visible and the area was infected.
Again this was not picked up by the Care Home. Mr Bere was readmitted to hospital
where the screws were removed and the infection was treated. As a result of the
ongoing infection all the metalwork had to be removed and this took place on 23" May
2012. Sadly Mr Bere did not recover from this medical intervention and he slowly
deteriorated and died on 4'" June 2012.
5 | CORONER’S CONCERNS
The MATTERS OF CONCERN are as follows. —
(1) There was evidence provided at the Inquest that showed that the Cardex system
used at the home was not being properly completed. Dates, on occasions,
appeared to be out of order and important information such where a patient had
fallen was not being recorded. Family concerns also did not appear to always be
recorded.
Incident reports were being completed but in Mr Bere’s case his incident report was
not followed up or updated even when further information was available as to the
extent of Mr Bere’s injury.
The lack of cross referencing or monitoring of these Cardex system and the
Incident reports appears to have been the reason why Mr Bere’s injuries were not
picked up soon by staff.
(2
(3
6 | ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you AND/OR
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 29" August 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 se! ort to the Chief Coroner and to the following Interested
Persons a Mr Bere’s daughter) and Goodlaw, Solicitors,
| 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.
4 July 2014 SIGNED — Penelope Schofield (Senior Coroner — West Sussex)
4
{ oa en ?
— A
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.
me) Older rarer N Assistant Director pro fy) People’s a Services i Date: 15 August 2014 Ref: Private and Confidential. _ Penelope A Schofield ol Senior Coroner D E C E ~ Vy E Coroner's Office 18 AUG 2014 | West Sussex Record Office L Orchard Street Chichester ee a a West Sussex PO19 1DD Dear Ms. Schofield Re: Inquest into the death of Stanley Bere - 29 May 2014. Thank you very much for your letter and report relating to death of Mr. Bere. We have tightened up our reporting systems, particularly ensuring all falls, accidents and "near misses" are recorded, and updating on any accident or incident. A more secure system of archiving has been introduced. We have also found a copy of a receipt we asked the coroner's officer to sign when taking the records, as she had no letter with her. | have enclosed a copy for your records. The home manager regularly checks that issues are recorded and followed up in his regular auditing of documents. Staff are aware of the consequences if they do not follow correct procedures. These improvements were put in place immediately following the inquest. It is unfortunate that although the care staff called the general practitioner, when Mr. Bere was sent to hospital, the hospital staff x-rayed his hip rather than his ankle. When he returned to the home, the general practitioner was called and staff were advised to wait a couple of days and then contact the general practitioner again. It was when he was contacted again that Mr. Bere went back to hospital and an x-ray revealed the fracture. The Kardex system does record that on 19 November 2011 Mr. Bere's dressing came off and staff referred him to the district nurses. They took over his care and redressed and cleaned the wound. There are four recorded items in the Kardex at that period of time. District nurses keep their own record of treatments for residents. We now ensure that we have a copy of their records and are aware of the current situation with each resident. Territorial Headquarters, 101 Newington Causeway, London SE1 6BN Switchboard: 020 73674500 Web: www.salvationarmy.org.uk Registered Charity No. 214779 and in Scotland $C009359; Social Trust Registered Charity No. 215174 and in Scotland SC037691 Republic of Ireland Registered Charity No. CHY6399; Guernsey Register Charity No. CH318; Jersey NPO0840 General: Andre Cox. Territorial Commander for the United Kingdom with the Republic of Ireland: Commissioner Clive Adams We appreciate that this report is specifically for us and are happy to provide details of our actions but it is disappointing that there is no mention of the verbal summing up of the narrative verdict where it was acknowledged that there were missed opportunities by all parties involved and that other professionals also had a part to play in the outcome. We note that we were given 56 days to respond to your report, which was dated 4 July 2014. However, the accompanying letter sent by your office is dated 24 July 2014, thus giving us only 35 days to respond. Yours sincerely Assistant Director of Older People's Services. Territorial Headquarters, 101 Newington Causeway, London SE1 6BN Switchboard: 020 73674500 Web: www.salvationarmy.org.uk Registered Charity No. 214779 and in Scotland $C009359; Social Trust Registered Charity No. 215174 and in Scotland $C037691 Republic of Ireland Registered Charity No. CHY6399; Guernsey Register Charity No. CH318; Jersey NPO0840
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