Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0413, written 18 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 | 18 Sep 2014 |
|---|---|
| Reference | 2014-0413 |
| Deceased | Marjorie Phillips |
| Coroner | John Pollard |
| Coroner area | Manchester South |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Managing Director, Sunrise Medical Limited, Wollaston, West Midlands. The Manager, Faversham Nursing Home, 59, Church Road, Urmston. 1 | CORONER 1am John Pollard, senior coroner, for the coroner area of South Manchester 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 the 18” April 2013 | commenced an investigation into the death of MARJORIE PHILLIPS dob 9" July 1928. The investigation concluded on the 18" September 2014 and the conclusion was one of a narrative verdict. The medical cause of death was 1a Type 2 respiratory failure 1b Left sided pneumonia 1c Multiple rib fractures (left) 11. Chronic obstructive Pulmonary Disease and osteoarthritis 4 | CIRCUMSTANCES OF THE DEATH The deceased who was a lady of 82 years of age, was being hoisted from her bed into a wheel chair when she fell from the hoist and landed on the metal supporting legs of the hoist. She died from resultant pneumonia several days later. 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. — During the course of the evidence | heard from an Inspector of the Health and Safety Executive that the sling had a tendency to “bagging” at the sides and if Mrs Phillips had leant her weight over to one side of the sling, this combined with the tendency of the sling material to “bag” might have allowed her to fall from the hoist.(FOR SUNRISE MEDICAL LIMITED) In-house training is given to the staff at Faversham Nursing Home in connection with matters relating to Health and Safety. It was apparent that the staff had not heeded the training or had not fully understood it as to the use of hoists. The training was said to include the fact that no-one should be lifted ina hoist when only one staff member was present. This was clearly not the case when Mrs Phillips was lifted.(FOR FAVERSHAM NURSING HOME) When a very serious untoward incident had occurred and Mrs Phillips had fallen and was in obvious severe pain, there was no clear guidance as to how the emergency servicessshould be called and by whom that decision could be taken. | This resulted in her not being taken to hospital as quickly as should have been the case.(FOR FAVERSHAM NURSING HOME) 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 44™ November 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 | have sent a co hief Coroner and to the following Interested Persons namel daughter of the deceased. | 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 rep entations to me, the coroner, at the time of your response, about the release id the/publication of your response by the Chief Coroner. — =a 9 18" September 2014 John Pollard, H.M. Senior Coroner
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.
For a full ist of offices visit www,inwinmtchell.com . . . “mM irwinmitchell ” sohcitors Your Ref: Our Ref: STRICTLY PRIVATE AND CONFIDENTIAL TO BE OPENED BY ADDRESSEE ONLY Mr JS Pollard Senior Coroner Coroner's Court 1 Mount Tabor Street Stockport 12 November 2014 Dear Sir MARJORIE PHILLIPS (DECEASED) We write in behalf of our client Sunrise Medical Limited following your request for their response to your Regulation 28 report (letter dated 18” September 2014). We understand that the matter for concern that you raise so far as our client is concerned is confined to paragraph 5.2 of your report, namely “During the course of the evidence | heard from an Inspector of the Health and Safety Executive that the sling had a tendency to "bagging” at the sides and if Mrs Phillips had leant her weight over to one side of the sling, this combined with the tendency of the sling material to “bag” might have allowed her to fall from the hoist. (FOR SUNRSE MEDICAL LIMITED)." and that in your opinion “action should be taken to prevent future deaths and you believe that our client have the power to take such action” (paragraph 6). It is difficult to provide you with any specific assistance based on the information provided within the report for the following reasons — respon» 0870 1500 100 . Rourscm East 2 Milsanas Shotisd 83.807 lex D114 275 3308 DX 1051 Steteis wevw inerentchell com Hes. wih number OCUSE97_ ang 16 etroraed ark npulated by ihe 5 ten Mca LP 3 hon tasty panes @e - bow Mich ty pannesn Oy @y Caesars Sokalons Sepvaion Autwrty The wad par ders 29 meer of He LLP e ary erapcrow OF ot Couto to. Me LLP fy any atsated ten to € B boy me memwers Uf and of those Reeecside Fas, 2 Milsanc:.. Shotiew, 85 BDT Non-members whe are SeSONSied 6: partners, 1. The date of this tragic incident and subsequent death of Ms Marjorie Phillips has not been referred to specifically. We infer from the reference to Ms Phillips being described as an 82 year old lady born in 1928 that the incident occurred in 2010. This date is significant on the basis that Sunrise Medical Ltd may not have-supplied the hoist in question ; 2. Sunrise Medical Ltd between 1983 -2010 was an affiliation of a total of three other companies to form a new holding company of Sunrise Medical Inc, one of which was Joerns Healthcare. (http://www.joerns.com/company). It is therefore not clear as to who may have provided the equipment in question as Joerns continued to trade under their own name from 2010, However, in the spirit of co-operation our client has requested that the attached Instructions for Use (IFU) documents be forwarded to you in the hope that they may assist. An IFU is supplied with each hoist which is delivered, and is model specific. The first IFU relates to the Oxford hoist which is no longer supplied by Sunrise Medical Ltd. It is submitted that if the IFU is a comprehensive document which at regular interval refers to safety precautions and bullets helpful “do's” and “don'ts”, specific references are made to the sling, maintenance of the same and operation of the hoist only with approved slings. On the basis that these hoists are no longer supplied by Sunrise Medical Ltd, it is submitted that if this was the hoist in question, no action can be taken by our client. The second IFU is the document in relation to Sunrise hoists. On the rear cover of the document you can see that the document was published as recently as July 2014. Page 1 starts with a clear advice that the equipment is not operated until the instruction manual has been read and understood. On the same page the reader / operator / customer is assured that Sunrise hold the CE mark and that the hoists meet a total of four CE directives. At the bottom of the same Page specific reference is made to the Lifting Operations and Lifting Equipment Regulations 1998 (LOLER). Safety instructions are clearly set out in easy to understand language at paragraph 3, Page 3 with further guidance and illustrations at Paragraph 9, page 7. Specific reference in made on page 3 (under the bold title “Before and during each use of the hoist’) that the sling should be checked to ensure it is of a type and size suitable for the patient and that it is adjusted @s per the relevant instructions for use. There are additional advice notes in relation to ensuring the patient's safety whilst being moved within the hoist. Perhaps of most significance at paragraph 11, page 8 under the heading of maintenance, customers are advised to subscribe to thorough inspections and tests of the equipment, including slings, every six Months. It recommends that the, following checks are made every day, before the hoist is used, specifically “check for wear on the hooks. Do not use slings which show signs of wear or damage in the liftin straps or sling body” which may include the “bagging” that you are concerned about in this matter. It is again submitted that this IFU is a comprehensive document which deals with the issues of purchase, maintenance and operation of equipment supplied by them, therefore no action is proposed at this stage. We trust this response deals adequately with the concerns that you have raised but should you require any further assistance, not to hesitate in contacting our client directly. Yours faithfully J IRWIN MITCHEEELLP &
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