Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0553, written 23 Dec 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Dec 2014 |
|---|---|
| Reference | 2014-0553 |
| Deceased | Alois Piska |
| Coroner | David Horsley |
| Coroner area | Portsmouth & South East Hampshire |
| 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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. MrM. Parish Chief Executive, Care UK Connaught House Colchester Business Park Colchester CO4 9QB Manager Harry Sotnick House Cranleigh Avenue Buckland Portsmouth PO1 5LU Head of Adult Social Care Portsmouth City Council Civic Offices Portsmouth PO1 2AL 1 | CORONER | am David Clark Horsley, senior coroner for the coroner area of Portsmouth and South East Hampshire. 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 3” June 2014 I commenced an investigation into the death of Alois Piska, aged 94. The investigation concluded at the end of the inquest on 17" October 2014. The conclusion of the inquest was that Mr Piska's medical cause of death was: - la: Subdural Haematoma - Ib: Head Injury - Ik Bronchopneumonia, Ischaemic Heart Disease and that he had died due to an Accident. 4 | CIRCUMSTANCES OF THE DEATH On 29" May 2014 Alois Piska was admitted to Queen Alexandra Hospital, Portsmouth, having fallen earlier that day in the lounge of the nursing home where he was a resident. No member of staff was present in the lounge when he fell. At the hospital he was diagnosed as having sustained a non-survivable head injury in the fall. He died peacefully at the hospital at 18.20 hours on 31° May 2014. 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. — There were inadequate numbers of staff at Harry Sotnick House to supervise residents in communal areas at all times when such areas are in use. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 17" February 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 Mr Piska's son and daughter. lam 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. 23 December 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.
Cofe & Mr David Horsley Care UK Community Partnerships , Limited Coroner s Office Hawker House The Guildhall 5-6 Napier Court Guildhall Square Napier Road Portsmouth RG1 SEW www.careuk.com RECEIVED 13 FEB 2015 | BY H.M CORONER 12 February 2015 Dear Mr Horsley Coroner’s Report to Prevent Future Deaths — Mr Alois PISKA (Date of Death: 31 May 2014) | write to address your concerns highlighted in the Regulation 28 report dated 23 December 2014. The matters addressed in the Report state that your concerns are, “that there were inadequate numbers of staff at Harry Sotnick House to supervise residents in communal areas at all times when such areas are in use.” To address your queries | have reviewed our internal records and guidelines and will explain each in turn: 1. Staff Rota for 29 May 2014 when Mr Piska suffered a fall On the 29" May | can confirm that the occupancy of the unit in question was 15 residents. The staff deployed to support these residents were: 1 Registered Nurse and 5 care staff which is a ratio of 1 member of staff to 2.5 residents. The industry average advises that there should be one member of staff for every 4 residents. CAPE (“Caring About People Everyday”) is an industry tool used to assess the nursing requirements for patients. The tables below show a comparison of nursing hours provided by Care UK in comparison with the recommended guidelines. Care UK Community Partnerships Limited. Registered in England No 02644862 Registered Office: Connaught House, 850 The Crescent, Colchester Business Park, Colchester, Essex CO4 908 Table 1: Average hours of nursing recommended by the RCN (“Royal College of Nursing”). CAPE Dependency Range RCNNI | Need Hours 0 8 Self Caring 1.0 | 9 17 Low 2.0 | 18 26 Medium 3.0 | 27 36 High 4.0 | Table 2: Average hours of nursing recommended and used by Care UK. Need Self Caring | Low Medium High Therefore, for the date in question, the unit was in fact over- staffed if compared to the industry average. 2. Particular care needs for residents Staff are deployed in the unit based on the identified needs of the residents. We do advocate that when clients are sat in communal areas there is a member of staff to support them. Due to the unpredictability and the nature of the Dementia disease it is extremely difficult to anticipate when a client may attempt to mobilise and subsequently have a fall in any area of the home, be it a communal area or their room. Risk assessments for falls are completed on every resident in the home and updated monthly. These assessments consider gender, age, falls history, sensory deficits, medication, medical history, mobility and gait. The assessment scores a risk and puts them into a high, medium or low category. Depending on the category, then depends on the care and the support that they are provided with e.g review medication, physiotherapy, opticians, etc. Mr Piska was classified ‘low’ as it was indicated in the plan of care that he was not mobile. Staff members are trained not to catch residents if they fall. This is to prevent injury to both resident and staff member. Therefore, even if a member of staff was present when Mr Piska fell, they would not have been able to prevent him from falling. On the 29" May it is my view that there were appropriate numbers of staff in the unit in question to meet the needs of the residents at that time | hope you find the response acceptable. Please do not hesitate to request further information should this be required. Page 2 of 3 Yours sincerely. Group Legal Director Page 3 of 3
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