Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0399, written 10 Sep 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Sep 2014 |
|---|---|
| Reference | 2014-0399 |
| Deceased | Gloria Foster |
| Coroner | Richard Travers |
| Coroner area | Surrey |
| Category | Other 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.
IN THE SURREY CORONER’S COURT IN THE MATTER OF: __________________________________________________________ The Inquests Touching the Death of Gloria FOSTER A Regulation 28 Report – Action to Prevent Future Deaths __________________________________________________________ THIS REPORT IS BEING SENT TO: 1. The Chief Executive of Surrey County Council in relation to paragraphs 5(1) to (4). 2. The Chairman of the Care Quality Commission in relation to paragraph 5(4). 1 CORONER Richard Travers HM Senior Coroner for Surrey 2 CORONER’S LEGAL POWERS I make this report under paragraph 7(1) of Schedule 5 to The Coroners and Justice Act 2009. 3 INVESTIGATION and INQUEST The inquest into Mrs FOSTER’s death was opened on the 12th February 2013 and was resumed on 1st September 2014. It was concluded on 9th July 2014. The cause of death was: 1a. Pulmonary thromboembolism 1b. Deep venous thrombosis. The conclusion was: Mrs Gloria Foster died from natural causes contributed to by neglect. 4 CIRCUMSTANCES OF THE DEATH By January 2013 a decision had been taken by the Metropolitan Police and the UK Border Agency to close a care provider by the name of Carefirst 24 (‘the Company’). The closure was to be marked by a raid on the Company’s offices which was due to take place on the morning of the 15th January 2013. The Company provided care for, amongst others, some thirteen people in Surrey, one of whom was Mrs Foster. Surrey County Council (‘the Council’) were made aware of the pending closure. By 1 MS4269 Rtdoc/00464‐2013/Reg28/23.10.2014 Friday 11th January 2013 the Council were aware of all but three of the service users whose care was provided by the Company and set about making alternative care arrangements for them. Following the raid the details of the remaining three service users were made available to the Council. All three of those remaining service users, who included Mrs Foster, were funding their care privately. By 13.00 hours on the 15th January 2013 Mrs Foster’s details, including the nature and the frequency of the care provided, namely four times per day, were known to the Banstead and Reigate Locality team, being the team within the Council with responsibility for organising an alternative care package on her behalf. In the event, nothing was done to arrange alternative care. Consequently, Mrs Foster was left on her own, incapable of looking after herself and with no care, for a period of nine days until she was discovered by a District Nurse. She was admitted to Epsom General Hospital very seriously ill and received treatment for a number of different problems including dehydration. Despite that treatment, she died on the 4th February 2013, whilst still at the hospital. The immobility and the dehydration from that nine day period was found to have made a material contribution to the cause of her death. No proper explanation was given by the Council for the failure to arrange suitable alternative care. The Banstead and Reigate Locality Team were under great pressure of work at the time and the Senior Operation Lead from that team, to whom the task of arranging suitable alternative care had been delegated, said that she had been influenced by the fact that Mrs Foster was a ‘self‐funder’. She went on to say that there is a bit of an assumption that self funders can manage their own care or have help from others, and although she acknowledged that it was wrong, she said that that had played a part in her mind. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters that gave rise to concerns that circumstances creating a risk of other deaths will continue to exist in the future unless action is taken. The MATTERS OF CONCERN are as follows. – 1. The need to have a protocol relating to the provision of additional support for operational staff when the need to prioritise work surrounding the closure of a care provider arises. 2. The need for additional specific training to reinforce to staff the apparent dangers of taking a different attitude to the needs of 2 MS4269 Rtdoc/00464‐2013/Reg28/23.10.2014 3. The need for additional specific training to ensure that there is a clear understanding of the role of Team Leader in relation to the supervision of tasks delegated by them to other members of their team. 4. The need to ensure that when a care provider is closed, all lines of communication with that provider, including telephone and email, are managed so that anyone who uses any one of those lines to make contact with them is immediately informed of the current situation and of where to go to seek advice or help. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that the Chief Executive of Surrey Council County and the Chairman of the Quality Care Commission have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed. 8 COPIES I have sent a copy of this report to the following Interested Persons in the Inquest and to the Chief Coroner. 1. 2. 3. Surrey County Council 4. 5. 6. 9 Signed: Richard Travers DATED this 10th day of September 2014 3 MS4269 Rtdoc/00464‐2013/Reg28/23.10.2014
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.
CareQuality Commission Care Quality Commission Citygate Gallowgate Newcastle upon Tyne Mr Richard Travers NE1 4PA HM Coroner for Surrey Telephone: 03000 616161 HM Coroner's Court Fax: 03000 616171 Station Approach Woking www.cqc.org.uk Surrey GU22 7AP 17 March 2015 BY EMAIL and POST Regulation 28 Report: Mrs Gloria Foster Dear Mr Travers Thank you for your letter dated 10 September 2014 in which you wrote to us under the provisions of Regulation 28 of the Coroners (Investigations) Regulations 2013 (‘the Regulations’) in relation to the inquest into the death of Gloria Foster. We were extremely saddened to learn of the death of Ms Foster and of the circumstances leading to her death. We are also extremely grateful for your report in requiring us to review what actions should be taken to prevent the occurrence or continuation of such circumstances in the future. Please treat this letter as the formal response of the Care Quality Commission (‘CQC’) to your report dated 10 September 2014. We apologise for the delay in responding to your report. The delay has resulted from careful consideration being given from operational and policy perspectives of the CQC’s response in operational and policy terms. In your report and pursuant to the requirements of Regulation 29 of the Regulations you require the CQC to provide details of any actions that it intends to take, or has taken to address the concerns highlighted in your report. In particular you required the CQC to consider the concerns outlined at paragraph 5(4) of your report as follows: ‘The need to ensure that when a care provider is closed, ail lines of communication with that provider, including telephone and email, are managed so that anyone who uses any one of those lines to make contact with them is immediately informed of the current situation and of where to go to seek advice or help” In drafting this response significant consideration and consultation has been given to your report by policy and operational teams. In particular we have considered what the current statutory framework empowers and obliges both the CQC and other relevant agencies to do in circumstances such as those that led to Mrs Foster's tragic death. The current statutory and regulatory framework does not confer on the CQC the duty or power to manage the lines of communication specifically in the way that you envisage. By contrast we understand that Local Authorities and Clinical Commissioning Groups (‘CCGs’) do have such primary duties and powers. Accordingly, those bodies are required to have sufficiently robust arrangements and procedures in place to ensure that they meet those duties without relying on third party agencies such as the CQC. The CQC does recognise the fundamental importance of notifying the relevant duty- holding agencies in circumstances where urgent cancellation is sought in order to avoid the possibility that circumstances such as those that led to the death of Ms Foster might arise. The CQC also recognises that such cooperation and notification is crucial. For that reason, the CQC has clear guidelines on who must be informed when we urgently cancel a provider's registration. Those guidelines were in place at the time of Ms Foster’s death and were followed in this case. We attach a copy of the guidance, which includes sets out as follows in particular at paragraph 11: “11. Do we need to inform anybody else that we have applied for an urgent cancellation of registration? Yes. As soon as possible after an application has been made, you must tell: * The Clinical Commissioning Group in which area the regulated activity (RA) is being carried on, where the regulated activity to which the Order relates involves, or is connected with, the provision of health care, and to the NHS England Area Team in connection with primary medical or dental care. * The local authority in whose area the regulated activity is being carried on, where the regulated activity to which the Order relates involves or is connected with the provision of social care. * Monitor, where the regulated activity or service is carried on by an NHS foundation trust. Or NHS Trust Development Authority, where the service provider is not currently an NHS foundation trust. * Any other people that we think are appropriate. For example, the Department of Health may need to know if we decide to cancel the registration of an NHS provider. We do this by giving notice of the application by phone call, then following this up by sending the ‘notifying others’ letter. There are email and letter templates for this in CRM. Note: For Notices of Proposal to cancel registration and Notices of Decision to cancel we would send a copy of the Notice.” We note from its response that the Local Authority acknowledges that the responsibility for managing the lines of communication lay in this case with them. We also note that the Local Authority has undertaken to take steps to address the deficiencies that this incident highlighted. We respectfully suggest that it might be prudent for the Local Authority to seek to ensure that the same issues are addressed across all local authorities nationally by working with the Association of Directors of Adult Social Services ((ADASS’). We greatly value the intelligence provided in your report and intend to address the concern raised at paragraph 5(4) in particular. The CQC is currently also undertaking a detailed review designed to ensure that the valuable information provided by Regulation 28 reports, as well as from other sources of information, systematically and effectively into our intelligent monitoring, inspection and registration processes. We hope that this response addresses the concerns raised in your report. Please do not hesitate to contact us if we can be of any further assistance. Yours sincerely Head of Inspection Adult Social Care Directorate South East
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