Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0502, written 17 Nov 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Nov 2014 |
|---|---|
| Reference | 2014-0502 |
| Deceased | Gladys Smith |
| Coroner | Melanie Williamson |
| Coroner area | West Yorkshire (East) |
| Category | Care Home Health related deaths |
| Organisation named | Leeds Community Healthcare NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
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. Solicitor with Williamsons Solicitors for and on behalf of
2. Solicitor with Berrymans Lace Mawer LLP for and on
beh s Court Residential Care Home in Garforth, Near Leeds
3. eS | o." with Hempsons Solicitors for and on behalf of
Leeds Community Healthcare NHS Trust
4. BE Soiici10; with RadcliffesleBrasse P for and on behalf
Of ES and ae the Moorfield
House Surgery in Garforth Near Leeds
5. Solicitor with Leeds City Council Legal Services
6. NICE, 10 Spring Gardens, London
7. His Honour Judge Peter Thornton Q.C., Chief Coroner for England and
Wales
1 | CORONER
| am Melanie J Williamson, Assistant Coroner, for the Coroner area of West Yorkshire
(Eastern District)
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 19 July 2012 | commenced an investigation into the death of Mrs Gladys Smith aged
88 years. The investigation concluded at the end of the inquest on 10 October 2014.
The Conclusion of the inquest was a Narrative Conclusion, a copy of which is annexed
hereto.
4 | CIRCUMSTANCES OF THE DEATH
Please see attached Narrative Conclusion
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) THE CARE HOME
(a) Advice and instruction given to Care Home staff as to the turning and
frepositioning of Mrs Smith was not followed and repositioning charts were not
(b)
{c)
(d)
(e)
(f)
(h)
(2)
(a)
(b)
(c)
completed. In the circumstances, all Care Home staff should ensure that all
advice and instruction given by medical practitioners, that is to say by General
Practitioners and District Nurses, in relation to residents is appropriately
implemented and that turning/repositioning charts are completed;
None of the bruises sustained by Mrs Smith, in particular the one which was
noticed on the 25 May 2012, were body mapped by Care Home staff. In the
circumstances, staff should ensure that all bruises sustained by residents are
carefully body mapped at the first available opportunity;
On or around 25 May 2012 bruising on the left side of Mrs Smith's bottom cheek
was noted by Care Home staff together with a blister. However, District Nurse
attendance in respect of an open area on Mrs Smith's bottom on her left side
took place 7 (seven) days later on 11 June 2012. In the circumstances, Care
Home staff should ensure appropriate medical advice is sought at the first
available opportunity upon noticing a bruise to a resident following an apparent
impact injury;
Falls assessments in respect of Mrs Smith whilst a resident at the Care Home
were not regularly undertaken and no consideration was at any time given by
Care Home staff as to the most appropriate location for Mrs Smith’s room within
the Care Home. In the circumstances, falls assessments should be regularly
undertaken in respect of all residents and regular consideration should be given
as to the appropriate location of residents’ rooms within the Care Home:
Between January and June 2012 Mrs Smith lost a total of 28lbs in weight. Mrs
Smith’s weight was neither regularly monitored nor regularly and fully recorded.
In the circumstances, Care Home staff should ensure that there is regular
monitoring and appropriate recording of residents’ weights’;
Despite the aforesaid weight loss experienced by Mrs Smith, at no time was a
nutrition chart implemented in order to monitor Mrs Smith’s nutritional intake.
Moreover, medical advice in relation to Mrs Smith's weight loss was only sought
a number of weeks after the commencement of the said weight loss. In the
circumstances, Care Home staff should ensure nutrition charts are completed in
respect of any resident whose weight falls significantly and should ensure
appropriate medical advice is sought at the first available opportunity following
such a fall in weight;
Mrs Smith suffered from vascular dementia and had done so since the
commencement of her residency at the Care Home. A number of other
residents suffer from dementia. Care Assistants at the said Care Home have
little or no knowledge of dementia and, consequently, how to care for residents
suffering from such a condition. In the circumstances, all Care Home staff
should undergo more indepth training in relation to dementia;
Care Home staff do not proactively enquire of medical practitioners as to how to
care for residents with certain medical conditions — for example, hiatus hernias,
dementia. In the circumstances, Care Home staff should ensure proactive
enquiries are made of relevant medical practitioners at the earliest opportunity
as to the appropriate care for residents suffering from recognised medical
conditions.
LEEDS COMMUNITY HEALTHCARE NHS TRUST
Members of the District Nursing Team who attended upon Mrs smith did not,
upon each visit, fully record and document the dimensions and presenting
features of the wound. In the circumstances, the Trust should ensure District
Nurses do record and document all bruises and/or wounds, in particular the
dimensions of the same together with a detailed description as to all presenting
features;
Mrs Smith was referred to the Tissue Viability Nurse Service on or around 25
June 2012, some 12 days after a referral ought to have been made according to
expert evidence adduced in the course of the inquest. In the circumstances, the
Trust should ensure District Nurses make referrals to the Tissue Viability Nurse
Service timeously;
The Trusts Clinical Guidelines for Wound Management in Adults and Children
omits to provide guidance as to when District Nurses should refer patients to the
Tissue Viability Nurse Service. In the circumstances, the Trust should amend
the said Clinical Guidelines in order to provide comprehensive guidance as to
when such a referral to the said Service should be made
(3) NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE
{a) There are no NICE guidelines which provide any comprehensive guidance to
Medical Practitioners in relation to the prevention and treatment of wounds and
ulcers caused by impact injuries. Clinical Guideline 29 — The prevention and
treatment of pressure ulcers, does not give guidance in respect of
wounds/ulcers caused by impact injuries. In the circumstances there should be
national guidelines which deal with such
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you
[AND/OR your organisation] have 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 12 January 2015, |, 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 sent a copy of my report to the Chief Coroner and to the follow)
Persons ; a
and to NICE.
| 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.
17 November 2014 A Melanie J Williamson
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