Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0029, written 29 Jan 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Jan 2015 |
|---|---|
| Reference | 2015-0029 |
| Deceased | Margaret Flemming |
| Coroner | Thomas Osborne |
| Coroner area | Bedfordshire & Luton |
| Category | Care Home Health 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.
THOMAS R. OSBORNE
Senior Coroner for Bedfordshire and Luton
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Mr Richard Carr
The Chief Executive
Central Bedfordshire Council
Priory House
Monks Walk
Chicksands
SG17 5TQ
1
CORONER
I am Thomas R. Osborne, Senior Coroner for Bedfordshire and Luton
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On 20th January 2015 I commenced an Investigation into the death of Margaret
Emily FLEMMING, aged 90 . The Investigation concluded at the end of the
Inquest on 21st January 2015. The Conclusion of the inquest was ‘Natural
Causes’. She had died from:
I(a) Bronchopneumonia
II End Stage Senile Dementia
4
CIRCUMSTANCES OF THE DEATH
The deceased had been a resident at the Care Home since 2009. Due to her
dementia she was placed on a Deprivation of Liberty Authorisation in October
2014. Over the weekend of 17th and 18th January 2015 she was seen by a Doctor
Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX
Tel 0300-300-6559 | Fax 0300-300-8267
and prescribed antibiotics. She died peacefully at the care home the following
day.
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. An urgent Request
for a Deprivation of Liberty Safeguarding
Authorisation was placed with Central Bedfordshire Council on 8th
October 2014 and yet the Best Interests Assessment did not take place
until 7th January 2015. The deceased remained vulnerable throughout this
period.
2. The Local Authority were aware for a long period of time that the
deceased had become confused and required urgent assessment.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I 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 26th March 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 family of Mrs Flemming.
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
Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX
Tel 0300-300-6559 | Fax 0300-300-8267
Coroner, at the time of your Response, about the release or the publication of
your response by the Chief Coroner.
Dated 29th January 2015
……………………………………..
THOMAS R. OSBORNE
Senior Coroner
for Bedfordshire and Luton
Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX
Tel 0300-300-6559 | Fax 0300-300-8267
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.
Mr Thomas R Osborne Your ref: FY
HM Senior Coroner :
The Court House Our ref: .
Wobum Sireet Date: 42" March 2015
Ampthill
Bedfordshire MK45 2+1X
Dear Mr Osborne
Inquest touching the death of Margaret Emily Flemming
Thank you for your letter dated 20" January 2015. | will respond to the
concerns in Section 6 ‘Coroners Concems’ of your Regulation 28 Repert in turn:
4. Deprivation of Liberty Safeguards {DoLS): urgent and standard
authorisation requests were received by the Council from Carringion House
care hame on 8" October 2074, The reason for the requests was that Mrs
Flemming lacked the option te leave the care setting and required continuous
supervision and control. You expressed your concern that the Best interests
Assessment did not take place until 7" January 2015 and you felt that the
deceased remained vulnerable during this time.
Since March 2014, the Council has adopted a risk based approach,
prioritising DoLS assessments on the basis of risk of harm to the person
concemed, and using a waiting list for those assessed as low risk. As there
was no indication of concern with Mrs Flemming’s care package, ho
concems faised by her family, and no indication of undue or excessive
physical or medical restraint being used, the request relating to Mrs
Flemming was assessed as low risk. Because of this, it meant that Mrs
Flemming’s Best Interests Assessment did ct take place until
gM january 2015. The outcome of this was that restrictions amounting ic
continuous supervision and control had been in place for frequent and
projonged periods since Mrs Flemming’s admission on 22"4 May 2008, she
was not free to leave, and the placement was in her best interests. No
changes to the care plan (conditions) were recommended as a result of the
assessment.
Cont/2....
Ceriral Besarishts Cours!
Priory House, Monks Watk Telephone 0300 300 8000
Chicksands, Shefford Email customer.services@centralbedfordshire.gov.uk
Bedfordshire SG17 §TQ www.centralbedfordshire.gov.uk
~2-
2. Whilst the Council! acknowledges that Mrs Flemming did not receive a DoLS
assessment within the timescales prescribed by law, we are satisfied that the
care being provided to her during that fime was appropriate and in her best
interests, An annual review of her care package had been conducted by a
socia! worker on 29” September 2014 and Best Interests Assessment on
g" January 2015. During this period there were no reports to the Council that
the care home was unable to meet Mrs Flemming’s needs.
The Council has adopted the prioritisation approach and waiting list as 4
temporary measure, in order to be able to respond to the ten fold increase in
DoLS activity. Part of the strategy to respond to this increase has been to
recruit temporary qualified staff, and train additional staff to perform the Best
Interests Assessor function. The Council is maintaining its investment in
these staff to deal with ihe increase in activity.
Whilst the waiting list is reducing (from 237 in January to 209 In February)
this is not a position the Council wishes to maintain. We are currently in the
process of procuring external specialist support to undertake ail of the
assessments on the waiting list.
if you wish to discuss this matter further, please contact Director of
Social Care, Health and Housing and
Hoad of Quality improvement & Safeguarding
| think it would be helpful for there to
be a discussion about your comments that action should be taken to prevent
future deaths. If would appear that Mrs Flemming’s death was due to
bronchopneumonia and End Stage Senile Dementia.
Yours sincerely
Richard Carr
Chief Executive
Direct telephone Il
| A
cc Director of Social Care, Health & Housing
Head of Safeguarding & Quality Improvement
eS TUNG
Walk | Telephone 0300 300 6000
Priory House, Monks
Chicksands, Shefford
Bedfordshire SG17 5TQ
Email customer.services@centralbedfordshire.gov.uk
www.centralbedfordshire.gov.uk
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