Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0514, written 25 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 | 25 Nov 2014 |
|---|---|
| Reference | 2014-0514 |
| Deceased | Michael Harman |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| Category | Community health care and emergency services 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.
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: Business Manager - Eastern Region Centra Support Central House 1-3 Highbury Station Road London N1 1SE Managing Director Centra Support Central House 1-3 Highbury Station Road London N1 1SE 1 CORONER I am JACQUELINE LAKE, senior coroner, for the coroner area of NORFOLK 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 7 August 2014 I commenced an investigation into the death of MICHAEL TERENCE HARMAN, AGED 73 years. The investigation concluded at the end of the inquest on 20 November 2014. The conclusion of the inquest was medical cause of death: 1a) Pneumonia; 1b) Hypernatraemia and Dehydration; 1c) Neglect; 2 Ischaemic Stroke (Old) Acute Kidney Injury and a narrative conclusion: “Mr Harman was seen on 18 July 2014. He was then spoken to daily but not seen. On 28 July 2014 he was seen and due to concerns regarding his welfare he was taken to Hospital. His condition deteriorated and he died on 3 August 2014.” 4 CIRCUMSTANCES OF THE DEATH Mr Harman lived in a sheltered housing scheme, offering independent living with support offered as and when required and signposting to other services as requested by the tenant. An emergency pull cord is in place and no face to face contact unless requested. He was seen by a support Co-Ordinator on 18 July 2014 when his flat was messy (unusual for him), he had soiled himself, he had “clearly been drinking [alcohol] but was not drunk”. He was partially dressed with soiled pyjama bottoms by the side of his chair. He refused assistance to clean himself saying he would do this himself. A warden gave evidence that he later saw Mr Harman through a glazed door near to his bathroom. Attempts were made to contact Mr Harman’s family: a nephew agreed to try and call on him. Mr Harman was at this time receiving the maximum amount of support offered by this form of independent living. He was felt by the Co-Ordinator to have mental capacity. 1 A cover support Co-Ordinator contacted Mr Harman by intercom each day from 21 to 25 July 2014 when he did stated he did not require any extra support. On 28 July 2014 the original support Co-Ordinator returned from holiday and there was limited response from him via the intercom – he made a “noise”. The Support Co- Ordinator entered the property and found Mr Harman unresponsive, naked, collapsed in his chair and having soiled himself with soiled clothes on the floor. He was taken to Hospital and diagnosed with acute kidney injury secondary to severe dehydration. He had a grade 2 large pressure sore covering his buttocks and the backs of his thighs. The evidence of the Doctor was that this was most likely caused by a lengthy period of immobility and sitting in excrement. Despite treatment, Mr Harman died. 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) After being found in a soiled condition, no check was made on Mr Harman to ensure he had cleaned himself as he said he would do. (2) There were several indicators that Mr Harman’s condition had possibly deteriorated to a point where he was no longer suitable for independent living, such as his flat being unusually untidy, his relapse in respect of drinking alcohol, his having soiled himself, his physical problems (he had recently been diagnosed with cellulitis). He was also receiving the maximum amount of support which could be offered. (3) Reviews of a tenant such as Mr Harman are annual, unless the tenant requests a review. No thought had been given to anyone else carrying out a review of Mr Harman’s condition particularly in the light of the above factors (4) Handover notes between Co-Ordinator and Cover Co-Ordinator deal with whether a tenant is likely to be at home when the intercom call is made. No note was made requesting a check to be made to ensure Mr Harman had cleaned himself up. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 23 January 2015. 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: and Legal Services & Complaints Manager at Norfolk & Norwich University Hospital I have also sent it to: 2 Director of Community Services at Norfolk County 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 25 November 2014 ……………………………………………. [SIGNED BY CORONER] 3
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.
Centra 27 JAN 2015 Support” Jaqueline Lake Senior Coroner . —— Norfolk Coroner's Service Enhancing Life Chances 69-75 Thorpe Road Norwich . Beacon House NR1 1UA ‘ 23 Hostmoor Avenue March Cambridgeshire PE15 OAX Tl 23/01/15 e———— Fai] www.centragroup.org.uk Dear Jaqueline, Re: Mr Michael Terence Harman Thank you for your report dated 25" November 2014, please find our response below. Before detailing our proposed actions and timetable, | have provided responses to some of the issues highlighted in the report. This is to provide further clarity about the service we offer and the circumstances. surrounding.Mr Harman's death. Centra’s Older Person’s Support offer in North Norfolk : f Potential tenants are assessed for their eligibility to move into sheltered accommodation and have a tenancy agreement directly with the landlord, in this case Victory Housing Trust. People within sheltered housing have a Varying degree of need and all are encouraged to be ’ as independent as possible. Often people's needs change over time but this does not automatically. mean that their tenancy agreement would need to come to an end. Local authorities seek to support people in making their own choices and to maintain their preferred lifestyle. Increasingly, this means that people remain in their own homes for as long as possible and that their support and. care needs are met in their own home. ‘The housing related support service provided by Centra involves two main elements: the welfare. check and the face to face visit. The welfare check is usually completed remotely through the warden call system and is a brief check with the tenant to make sure they are well and to offer an opportunity to that person to request additional support. Face to face support is arranged on an appointment basis. with a defined purpose and outcome. The role is to provide housing related support to tenants within the schemes. This can include things like supporting people to manage their money, maximise their income, make links to health and social care, signpost to other services, and to encourage mutual support by tenants. The support coordinators travel between different sheltered schemes to provide this support and they do not remain static in one location. This’ means that tenants are encouraged to request support as and when it is needed, rather than having the support coordinator seek them out to offer support. This is in accordance with the service specification as commissioned by Norfolk County Council, as well as promoting independence, choice and control amongst the tenants. ES, INVESTORS Circle Housing welcomes calls from Text Relay. If calling from a textphone 4d! IN PEOPLE @® please dial the prefix 18001 and the number you wish to contact. sole Care ard Support Limiced is acamipany England and Wales No, 2307084 teding a3 Centra Support Registered Ofice: Circle House, 4 Highbury Station Road Lendoa Nt Se ci Registered Charity No, 1107432 Part of Circle THCESIG 0514 Within the sheltered schemes, including Mr Harman's flat is an emergency ‘warden call system’. By pressing a call button or by pulling one of the emergency pull-cords in the flats and communal areas tenants have access to a call handler 24hrs a day. The call handlers have access to personal information and contacts for every tenant within the sheltered scheme. The call handlers are trained to respond to emergencies by taking important information and raising an alert with the emergency services, the person’s next of kin and during working hours with the support coordinators. The call handlers also receive non- emergency calls and raise alerts as appropriate and agreed with the individuals concerned. Provision of personal care in the community is regulated by the Care Quality Commission and is employed to support people to remain in their own homes for as long as possible. This provision depends on the person's needs and preferences and can include several visits a day from care workers. With the exception of people who are able and willing to pay for and organise their own care, the majority of care at home is managed through local authority adult care services. This includes the assessment of individuals requiring care, against the Fair Access to Care Services eligibility criteria before the focal authority commissions a ‘package of care’ for that person. The time frame from first contact with the local authority to receiving care is variable but not immediate. : Norfolk County Council provides a service called ‘Norfolk Swift Response’. This service is regulated by the CQC and can assist with getting up, washing, dressing and falls. It is available for people who have an urgent, unplanned need for care at home but who don't require the emergency services. Response to concerns raised in the report ¢ Section 4: Clarification: At the inquest evidence was given that Centra Support Coordinator made a referral to Norfolk Swift Response and requested that the service attend Mr Harman on 18" July 2014 to support him to manage his personal care. Norfolk Swift Response declined to attend because Mr Harman’s difficult situation was regarded _as due to his use of alcohol rather than the result of an ongoing personal care need. HE wes not able to directly support Mr Harman with his personal care as this is an activity regulated by the Care Quality Commission. The sheltered support service is not regulated by the CQC and so support with this activity is prohibited. [EEE made contact with Mr Harman’s family to let them know about his difficulties. ¢ Section 4: Clarification: ‘a warden gave evidence that he later saw:Mr Harman’. The person who gave this evidence was actually a Housing Officer employed at the _ time by the landlord, Victory Housing Trust. ¢ Section 5 (2): Clarification: ‘Mr Harman...was no longer suitable for independent living’. With regard to the Mental Capacity Act we believe that Mr Harman had capacity, and as such was fully able to make his own choices about his living arrangements. The local authority, medical practitioners and the support service would have no legal authority to remove him from his accommodation. Mr Harman had a tenancy agreement between himself and the fandlord (Victory Housing Trust). As already described, community care services are provided through the local authority to support people to remain in their own homes for as long as possible, as well as to support swift hospital discharges. A person may live in sheltered accommodation and receive housing related support, have a 24hr warden call system and also be in receipt of a ‘care package’. The maximum amount of support referred to in the report, was only the housing related support element offered by Centra. ¢ Section 5 (3): Clarification: Centra’s support service is service user led and therefore the review process requires the tenant to engage with a review. In this situation, an immediate review ‘of’ Mr Harman and his situation would have resulted in a referral to Norfolk First Response for immediate support, along with a referral to Norfolk Adult Care Services to request an assessment for care at home. It is likely that a planned review ‘with’ Mr Harman would have resulted in the same recommendation. It is important to note that being assessed for and receiving care at home would require Mr Harman’s consent. Evidence given at the inquest indicated that Mr Harman had previously declined a care at home service. Again, evidence was given at the inquest indicating that the immediate need was in fact referred to Norfolk First Response by Centra staff. ¢ The report does not appear to fully recognise that Mr Harman found himself in a very difficult situation on the 18" July as a direct result of alcoho! abuse and that this had been a previous pattern of behaviour. As such, an ongoing need requiring a referral for care at home may not have been immediately evident. e The report does not appear to fully recognise that Mr Harman had access to the warden call system for emergency assistance but did not make use of it. « It would have been helpful to have had a.representative from Norfolk County Council Adult Care Services present to give evidence describing the sheltered accommodation, the support service, to give a history of Mr Harman’s previous care at home service and to elaborate on why the referral made by Centra to Norfolk First Response was not accepted. Actions and timetable After reviewing the concerns raised in your report, the following actions have been planned / taken. _ oo . Be eee . Nov/Dec | Completed - Review has been carried out and recommendations presented to the Regional Business Manager. _ © 7 Locality Business Manager Action Full internal review of working practices in the service to be carried out. Full review of welfare checks | Locality Nov/Dec | Completed - Review has been and warden call response Business carried out and recommendations process. Manager presented to the Regional Business Manager. Discuss outcome of welfare January | In progress - discussion is check and warden call ongoing with the Service review with Service Commissioner from Norfolk Commissioner. County Council to consider alternative ways of carrying out welfare checks so that support coordinators can focus more on support related tasks and face to face contact. Draw up and rolt out local Locality January | Completed — please see attached guidance protocols for Business guidance document. (1) Reporting of Manager accidents, incidents and near misses. (2) Follow up with a service user when an accident, incident or near miss has been reported (3) Making onward referrals ; (4) When to undertake scheduled and unscheduled reviews Audit schedule developed to | Team End of To be completed check understanding and Manager _| January compliance with new tocal guidance. | hope this response provides assurances that we are taking appropriate steps to ensure the continued safety and wellbeing of any person that uses our services. We take our responsibilities around health and wellbeing very seriously and welcome all feedback and suggestions for improvements in our working practices. We have taken note of your concerns and are taking appropriate actions to ensure that the risk of a similar incident occurring are minimised. If you have any further questions or require any clarification please do not hesitate to let me know. Yours Sincerely, Regional Business Manager - Eastern Region — Centra Care and Support Phone: E-mail: [a ar
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