Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0057, written 17 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 | 17 Feb 2015 |
|---|---|
| Reference | 2015-0057 |
| Deceased | George Marks |
| Coroner | Kate Thomas |
| Coroner area | Mid Kent & Medway |
| Category | Hospital Death (Clinical Procedures and medical management) 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) [3 2 | CORONER’S LEGAL POWERS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. MAYDAY HEALTH CARE PLC CORONER 1 am Kate Thomas Assistant Coroner, for the coroner area of Mid Kent and Medway. | 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. INVESTIGATION and INQUEST On the 20" of March 2014 | commenced an investigation into the death of George Marks, Aged 93. The investigation concluded at the end of the inquest on the 5" of November 2014. The conclusion of the inquest was natural causes contributed to by neglect. a ee CIRCUMSTANCES OF THE DEATH Mr Marks was admitted in to A&E Dept on the 14" of February 2014 with confusion, immobility and a chest infection. He was _ prescribed anticoagulant medication as a precaution given his age and immobility. The diagnosis of DVT was confirmed on the 24" of February when scans showed he had a DVT in the leg and right sided thrombus in the pulmonary artery. On the 27th of February a decision was made to change the anticoagulant medication to Rivoroxaban - administered orally. On the 27" of February Mr Marks was cared for by the first of a succession of agency nurses from the Mayday Healthcare PLC. From the evening of the 28" of February until the 4° of March, when a Doctor finally noticed, Mr Marks had failed to be given his medication and in particular the Rivoroxaban which was located in a ‘pod’ beside his bed. Mr Marks declined and died on the 6" of March 2014. A Consultant Haematologist at the Inquest said that it was unlikely that a new embolism would have formed had Mr Marks been administered Rivoroxaban and further, that there was a very high probability that the new embolism caused or contributed to his death. 15 | 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) Agency staff failed to have an understanding of the basic policies and procedures in place when administering medication and / or where a patient refused to take such medication. 2) Agency Staff failed to have an understanding of the Drug Prescription Chart and / or failed to make any record, or any adequate record in the said chart 3) Agency Staff failed to have an understanding of the need to make a record and or any adequate record in the patients nursing notes, 4) Agency Staff failed to adopt the correct “Hand Over’ procedure. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation 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 the 13" April 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 the following Interested Persons : Maidstone and Tunbridge Wells Trust: GM ( son of the Deceased ) . ! 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. 17" February 2015
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.
Mayday Healthcare PLC, 10 Lower Grosvenor Place, London SW1W OEN Tel: 08703 43 00 43 Fax: 020 8901 6744 e-mail: jobs@maydayhealthcareplc.co.uk www.maydayhealthcareplc.co.uk We care 24 hours a day Patricia Harding Maidstone Archbishops Place Mill Street Maidstone Kent 26/02/2015 Dear Madam, Re: Response to the inquest touching on the death of George Marks. We are writing in response to your letter dated 17 February 2015, we initially responded to you detailing the measurements that would be implemented in order to prevent a case such as this ever arising again. We have included a copy of the original letter that had been sent detailing those measurements, due to the initial timeframe in which we had to adopt these new processes they were initially designed. However, | am pleased to say that after three months these measures has been implemented and nurses are now reminded of their basic duties outlined by the NMC guidelines. Please see below a brief outline of the measurements that have now been implemented since the initial letter dated 24 November 2014, which detailed our proposal for change: e Ageneric SMS has been sent to all staff detailing the importance of documentation, escalation, administration of medication and compassion. This is done once a month to remind all staff of their basic duties. e All consultants that liaise with staff are now trained to remind the nurses of their basic duties before undertaking a shift and this has now been enforced amongst existing consultants as well as being incorporated in to the training of new recruits. © Feedback forms have been created and are distributed to clients on a regular basis, requesting for clinical work to be monitored and checked in accordance with the NMC guidelines. e Formal letters sent to all staff, detailing the importance of documentation, escalation, administration of medication and compassion. This is currently being done every quarter. ata Recruitment & Employment Confederation Registered office: Hygeia 66-68 College Road, Harrow, Middx HA1 1BE. Tel: 020 8861 3000. Registered in England and Wales No: 04983787. e Updated our yearly training program in regards to documentation, escalation, administration of medication and compassion, which is outside of the framework requirements for the Mandatory Training subjects We must state that our proposed changes and have been running for past three months and they now feature permanently in Mayday Healthcare PLC’s working practises. If you have any further questions or concerns please do not hesitate to contact me. Yours Sincerely Managers Mayday Healthcare PLC
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