Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0047, written 11 Feb 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Feb 2015 |
|---|---|
| Reference | 2015-0047 |
| Deceased | Anne Horner |
| Coroner | Simon Nelson |
| Coroner area | Manchester North |
| Category | Hospital Death (Clinical Procedures and medical management) 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: REPORTTO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORTTO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Department of Health 2. Bury MBC 3. Care Quality Commission 4. Messrs. Latimer Lee Solicitors on behalfofOak Lodge Care Home 5. Family ofthe deceased 6. Chief Coroner CORONER I am Simon Nelson, HM Senior Coronerforthe Coroner area of Manchester North 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, ofthe Coroner’s and Justice Act 2009 and Regulations 28 and 29 ofthe Coroners (Investigations) Regulations 2013 3 INVESTIGATION and INQUEST On the 7th April 2014 I commenced an investigation into the death of Anne Homer for whom the cause of death had been given as being that of la) Traumatic Acute Subdural Haemorrhage with Renal Cell Carcinoma with Lung Metastases; Anticoagulation Therapy, whilst not causative of death, being contributory factors under 2. At an Inquest at the Rochdale Coroners Court Heywood on the 2n2d January 2015, the following conclusion was reached ‘against a background of increasing frailty of health and use of anti-coagulation therapy Anne Homer died at The Salford Royal Hospital on the 2th5 March 2014 from a traumatic head injury precipitated initially by inadvertent impact with a toilet door which was being opened at Oak Lodge Care Home at approximately 05:l5hrs that day but which may have been aggravated by subsequent trauma following her collapse at approximately 09:40hrs that day whilst at the Care Home’. 4 CIRCUMSTANCES OF DEATH As above 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 reportto you. The MATTERS OF CONCERN are as follows: 1. The deceased had been a resident at Oak Lodge Nursing Home for approximately 6 weeks prior to her death during which time she was able to access and use bathroom facilities that were close to the bedroom which she occupied. 2. At approximately 02:3ohrs on the 6th March 2014 whilst Mrs Homer was within the toilet cubicle within the bathroom she sustained a minor head injury when the door to the cubicle struck her head as it was being opened by a Health Care Assistant who was undertaking room checks. 3. At approximately 05:30hrs on the 2th5 March 2014 Mrs Homer was involved in a virtually identical incident, again whilst sitting within the toilet cubicle. Sadly later that morning she was found unresponsive and notwithstanding her transfer to the emergency department at Salford Royal Hospital, she was diagnosed as having an unsurvivable brain injury. 4. The evidence at Inquest confirmed that the bathroom facility which included the toilet cubicle was constructed in or about 1988 in compliance with the relevant Planning Permission and Building Regulations. I accept that the facility had been used on many previous occasions without incident. The fact however that a resident sustained injury on two separate occasions within a period of 6 weeks gives rise to concern. I anticipate that there are many establishments within England and Wales where toilet facilities are not dissimilar to those at Oak Lodge Nursing Home. I understand that separate guidance in relation to disabled toilet design suggests doors that open outwards to facilitate access if someone falls behind the door. Whilst photographic images produced at Inquest suggested adequate door clearance for a resident sitting normally on the toilet, that would not be so for an individual resident who sat / was slumped forward. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to consider legislation that would prevent fatalities occurring in similar circumstances and I believe each ofyou respectively have the powerto 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 8th April 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 ChiefCoroner and to the following Interested Persons namely: 1. Department of Health 2. Bury MBC 3. Care Quality Commission 4. Messrs. Latimer Lee Solicitors on behalfofOak Lodge Care Home 5. Family ofthe deceased I am also under a duty to send the ChiefCoroner a copy ofyour response. The Chief Coroner may publish either or both in a complete or redacted or summary from. He may send a copy of this report to any person who he believes may find it usefulor 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 ChiefCoroner. 4c) g Date: 1th1 February 2015 Signed.(J,
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.
CareQuality Commission North Region Care Quality Commission Citygate Gallowgate 4 Newcastle upon Tyne NE1 4PA Mr S Nelson Telephone: 03000 616161 HM Senior Coroner Fax: 03000 616172 Office of HM Coroner The Phoenix Centre www.cqc.org.uk L/Cpl Stephen Shaw MC Way Heywood OL1O 1LR 20 March 2015 Our ref: Re: Anne Homer (deceased) Regulation 28 notice Dear Mr Nelson We were very sad to read about the death of Mrs Homer and the circumstances in which she died. Thank you for your report and the requirement for us to review what actions should be taken to try to prevent the occurrence or continuation of such circumstances in the future. Please treat this letter as the formal response of the Care Quality Commission (‘CQC’) to your report dated 11 February 2015. In terms of the actions that we have taken since theevent we have been in , dialogue with the provider requesting information relating to the incident. This has included requiring information from the provider under Section 64 of the Health and Social Care Act 2008. This information has now been provided. The provider has confirmed to us in writing that the toilet has been decommissioned and is no longer in use. We note your comment relating to toilet doors opening outwards. It seems to us that it would not be appropriate for the CQC to provide any expert comment in this area. We respecifully suggest that it would be more appropriate for the Building Control department of the Bury Metropolitan Borough Council to advise on such matters. We are mindful on the one hand that a door opening outwards into a corridor might reduce the risk of a person using the toilet striking their head against an opened door while increasing accessibility in the event of a fall. On the other hand, we also recognise that outward-opening doors may pose inherent risks to passers-by outside a toilet and especially so where a service is frequented by people who may have a visual impairment or mobility problems. It is the responsibility of the service provider to manage the risks posed by whichever mechanism it implements to ensure the welfare and safety of service users. Registered office: FinsburyTower, 103-105 Bunhill Row, London EC1Y8TG CareQuality Commission In terms of further actions that we have undertaken to address concerns highlighted in your report, the CQC has also inspected the home on an unannounced basis. The resultant report is currently in draft format and will shortly to be sent to the provider for comment and any factual accuracy representations. We have identified a number of areas the provider needs to address within the care home although none relate to the concerns raised in your report. If you wish we will send a copy of the report to you once it has been published. We hope that this letter adequately sets out the steps that the CQC has taken to address the concerns identified in your report following the inquest following into Mrs Homer’s very sad death. If we can be any further assistance please do not hesitate to contact us. Yours sincerely Head of Inspection Adult Social Care (North Central) Registered office: FinsburyTower, 103-105 Bunhill Row, London EC1Y8TG
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