Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0354, written 30 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 | 30 Jul 2014 |
|---|---|
| Reference | 2014-0354 |
| Deceased | Christopher Royal |
| Coroner | Lydia Brown |
| Coroner area | Leicester City & South Leicestershire |
| Category | Care Home Health related deaths |
| Organisation named | East Midlands Ambulance Service NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. 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. Mr Warren, Owner of Baron’s Park Nursing Home 1 CORONER I am Lydia Brown, assistant coroner, for the coroner area of Leicester City and South 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. 3 INVESTIGATION and INQUEST On 28 – 30th July 2014 I commenced an investigation into the death of Christopher John Royal, 67 years. The investigation concluded at the end of the inquest on 30th July 2014. The conclusion of the inquest was Cause of death - 1a Aspiration of stomach contents 1b Ischaemic heart disease Conclusion – Natural causes contributed to by neglect 4 CIRCUMSTANCES OF THE DEATH Mr. Royal was properly detained under a DOLS order, Mental Capacity Act 2005 which prevented him from leaving Baron’s Park Nursing Home. He suffered a cardiac event on 25 January 2013 and was found collapsed in his en-suite bathroom that evening. Staff attending to Mr. Royal from the Nursing Home but did not provide any, or any adequate First Aid. Paramedics were summoned but Mr. Royal was pronounced life extinct as CPR was unsuccessful. 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. – 1) Mr. Royal was on 15 minute observations. The observations were not carried out by a designated member of staff; there was no system in place; the recorded observations were unreliable and inaccurate; recordings were not made by the staff who had actually observed Mr. Royal. Consideration should be given to a more robust, safe and accountable observation system, and proper training and auditing to ensure this is in place and operating effectively. 1 2) Evidence was taken that the Matron did not have a valid First Aid Certificate at the time of this event; it had expired in 2011. There was evidence that the nursing home staff response to this medical emergency was inadequate and insufficient. One member of staff said although First Aid trained she did not feel competent to carry out CPR. First Aid training is essential in a Nursing Home environment, and there should be in place a proper system to ensure training is provided, updated, effective and understood. An annual system of review and/or appraisal may assist in the monitoring process and allow staff feedback and concerns reporting. 3) Matron said she regularly worked a 13.5 hour shift as it meant less travelling time as many staff lived a distance from the home. This length of shift may not be conducive to good health care and may have contributed to the poor care given that evening to Mr. Royal. Consideration should be given to whether shifts of this length are for the benefit of the residents or the staff, and if any perceived benefits outweigh any potential problems this type of shift pattern may create. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your 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 27th September 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 - East Midlands Ambulance Service NHS Trust - - Coventry Social Services - Coventry and Warwickshire Partnership Trust brothers of the deceased I have also sent it to the - Care Quality Commission and the - Nursing and Midwifery Council 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 30 July 2014 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.
\nq, Closed sud BAH Barons Park Care T: 0116 238 7337 F: 0116 238 7976 E: info@baronspark.co.uk W: www.baronspark.co.uk Mrs LC Brown Desford Lone - Assistant Coroner Leicester - LE9 2BE Leicester City & South Leicestershire HM CORONERS OFFICE The Town Hall Town Hall Square Leicester LE1 9BG 26" August 2014 Dear Mrs Brown Re: Christopher John ROYAL Following the completion of the investigation and inquest in respect of the death of Mr CJ ROYAL and upon receipt of your regulation 28 report, as required, we submit our response to address the matters of concern which were raised. We enclose our response on the accompanying pages. Yours sincerely Un, - Director Borons Park Care is the trading name of Barons Park Nursing Home Lid. Compony Registration No: 2874226 Nursing Home The Lakes Connexions Regulation 28: Response to report; Re: Mr CJ ROYAL 1. We take note of the report in respect of the unreliable and inaccurate recordings which were made for 15 minute observation requirements. In response to this we have; a) b) ¢) d) Reviewed our observation policy in line with matters highlighted (see appendix A, completed 1* August 2014). Issued policy to nursing staff (August 2014) Created a new record sheet for nursing staff to complete at the commencement and conclusion of shift. The sheet clearly identifies who is responsible for carrying out certain requirements and it places an onus on the nursing staff to review the sheet and the observation requirements (paperwork) at timely intervals (see appendix B, implemented i August 2014). Completion of observation sheets and allocation sheets are being monitored by our General Manager for audit purposes and to ensure that the new regime is being implemented in an accurate and effective manner. This is an ongoing process. We take note of the report and evidence that Matron’s First Aid Certificate had expired at the time of the event; In response to this we have; a) b) After the death of Mr Royal in January 2013, and upon finding at this time that Matron’s first aid training had lapsed, we immediately reviewed our training system and the implementation of such, and developed our skills matrix to highlight an overview of staff training. Since February 2013, we have developed a more robust training matrix which focuses on some of the key training of staff within a nursing environment. The matrix enclosed (appendix C), shows our progress to date and shows that the majority of our nursing and care staff have (during the past 18 months), undertaken training in many mandatory courses. This is an ongoing process and we enclose (appendix D) a copy of our training plan which shows our program for this year. We will continue to monitor staff training records. As part of this development, we now also allocate staff to attend sessions as opposed to our previous process of “open attendance requirements”. We have also added a clause to employment contracts which makes a requirement to keep training “in- date” and allows us to take further action if this is not the case. We are now ensuring that all nursing/care staff receive training in key areas. To monitor the effectiveness of this, we will be reviewing training sessions with staff to find out how effective the session has been and to find out if there are any remaining shortcomings. From our findings, we can arrange further training if needed, source an alternative provider or continue to implement if well received. We are commencing this program of monitoring and review with effect from 1* September 2014. 3. We continue to offer extensive training to all staff (as per our training plan), whilst the completed training of staff is closely monitored though our skills matrix. 4. Effectiveness of training is to be monitored by evaluation and feedback from course participants. 5. Working hours of staff will be monitored to ensure that arrangements benefit our residents as opposed to the requirements of staff members. Director Response and accompanying documents produced by Park Nursing Home Ltd ie: onBarons
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