Noreen Porter

HM Coroner Birmingham & Solihull

Bupa Care Services

Mrs Louise Hunt :
C Court Bridge House
oroners Cou Outwood Lane
50 Newton Street Horsforth
Birmingham Leeds
LS18 4UP
B4 6NE

T +44 (0)113 381 6100
F +44 (0)113 259 1229
bupa.co.uk/care-homes

16" February 2015

Dear Mrs Hunt
Noreen Mary Cecilia Porter deceased — Regulation 28 report to prevent future deaths

| write on behalf of Ardenlea Grove Nursing Home to respond to the Regulation 28 report
which you sent to FP the home manager, on 22"! December 2014.

In your report, you stated the matters of concern to be as follows:

1. No CPR was undertaken by the staff when the deceased collapsed;
2. There appears to be no process or procedure in place to ensure resuscitation in
undertaken when an emergency occurs.

During the inquest you heard evidence as to the circumstances of the deceased's collapse in
that she appeared to stop breathing whilst being assisted with her meal. You also heard
evidence of how the staff responded. Whilst the attending nurse did check for signs of
choking and the presence of food obstructing the airway, it is the case that CPR was not
commenced whilst the staff waited for the paramedics to attend.

It is Bupa’s policy that unless there is a valid DNACPR document in place, then CPR should
be commenced. Aside from the policy, all trained nurses are required to be aware of the
circumstances in which CPR should be commenced as part of their nurse training
competencies and continuous professional development requirements.

In the case of Mrs Porter, as you may have heard during the evidence, prior to her discharge
from hospital into Ardeniea Grove, Mrs Porter had a DNACPR document in place. This was
no longer valid upon discharge from hospital into a new care setting and with a new set of
care plans in place. The day after admission to the nursing home, the GP met with Mrs
Porter's family with a view to establishing a new DNACPR, but it was not signed off by the
GP because not all family members were in agreement. The staff caring for Mrs Porter were
aware that there was no valid DNACPR in place and therefore the default position in
accordance with Bupa’s policy is that CPR must be commenced in the case of respiratory
collapse.

Bupa Care Homes (ANS) Limited No. 1960990 Belmont Care Limited No. 2509860 Bupa Care Homes (AKW) Limited No. 4122364
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ex Bupa Care Homes (@NHP) Limited No. 3183275
Ys INVESTORS Registered in England and Wales, Registered Office: Bridge House, Outweod Lane, Hes sforlh, Leeds 1$18 4UP.
yoy IN PEOPLE | GO!d Bupa Care Homes (Carrick) Limited No. SCISI487. Registered Office: 39 Victoria Road, Glasgow G78 INO.
aod VAT Registration No. 239731641

The reason for the failure by the nurse to commence CPR in Mrs Porter's case was
investigated following the incident because it was apparent there had been a breach of Bupa
policy in this case. The nurse told the investigation that he was aware there was no valid
DNACPR for Mrs Porter and he was aware of Bupa’s policy. He said that events had
“happened quickly” and that he was unable to explain why he failed to attempt CPR on this
occasion. His response had been to check for signs of choking and to look for food particles
which might have been blocking the airway. Once he had completed that task he was unable
to explain why he did not take further steps or commence CPR pending the paramedics
attending.

Since this incident, the home manager at Ardenlea Grove has carried out the following steps
to ensure all staff are aware of Bupa’s policy and the steps that they must take in a similar
situation and to learn the lessons from this tragic incident.:

¢ Focussed supervisions have been carried out with all nursing staff employed at the
home to cover Bupa’s policy on CPR and the circumstances in which CPR must be
commenced;

¢ Bupa’s policies on resuscitation and choking have been re-issued to all staff:

¢ Refresher CPR training is being scheduled for delivery across the home (a refresher
training session had been scheduled prior to Mrs Porter’s death, however this had to
be cancelled due to an outbreak of Norovirus in the home and is now being re-
arranged) .

¢ Two more suction machines have been ordered so that there is now a machine on
each floor of the nursing home. We appreciate that this was raised by the
deceased's family during the inquest and | understand that the conclusion was that
suction was unlikely to have altered the outcome for Mrs Porter in these
circumstances. Nevertheless this case has caused the management team of
Ardenlea Grove to reappraise all the procedures and processes for life support in
place in the home and it was concluded that having a suction machine available on
each floor was appropriate based on the assessed risks and needs of the resident
population. These are now in place.

Bupa’s policies are of national application across all its care homes in the UK. Part of the
policy framework is that in all homes, it is a mandatory requirement that on each shift, there
is a trained nurse/ first aider who is competent in life support procedures on duty at all times
and that was indeed the case when Mrs Porter collapsed. It is therefore regrettable that the
appropriate procedures were not followed at the time.

In the circumstances, in relation to your two areas of concern:

1. We accept that in relation to this incident, CPR was not carried out on Mrs Porter
when it should have been;

2. | hope we have been able to satisfy you that there are appropriate policies and
procedures in place to direct staff to carry out CPR in appropriate cases, in response
to an emergency. Sadly, on this occasion the procedures in place were not followed
despite being known to the staff involved.

In order to help our staff to learn the lessons from this tragic incident, your report and this
response has been shared with our operational management teams so that the key

messages and learnings are cascaded to our other homes across Bupa and used as part of
the ongoing training and to reinforce the importance of Bupa’s policies and procedures.

| would like to apologise on Bupa’s behalf, to the family of Mrs Porter, that CPR was not
carried out as required. | would also like to send my condolences to the family, although |
recognise that this will be little comfort to them at this difficult time.

if |, or my colleagues can assist you further please do contact me. | can be reached on:

Telephone: ae

Yours —

Head of Legal — Provision