Michael Lyons

REPORT FROM JOHN STANLEY’S CARE AGENCY

John Stanley’s Care Agency is contracted by the London Borough of Havering to provide domiciliary
care in the community, on behalf of the council.

We were commissioned by Havering Social Services to provide care and support to Mr Michael
Lyons.

Once we have agreed to take a referral from Social Services, the following process takes place:

¢ Acompleted Support Planning document is received from a named Social Worker

¢ This document contains the Service User’s medical history and all personal details

¢ This document also contains a care diary, instructing what tasks are to be completed and
the length of time allocated for each visit

Prior to the commencement of any service, we are required to carry out our own full and detailed
care needs assessment with the service user and if desired, family member/advocate also in
attendance.

| would like to answer the following issues which you have raised in your report:
CIRCUMSTANCES OF THE DEATH

When the agency were first engaged, information was provided to them about Mr Lyons’ difficulty
with swallowing. Part of the need for carers to attend Mr Lyons was to assist and supervise him
with feeding.

1 April 2014:

The support planning paperwork we received clearly states the tasks we are expected to complete.
Each morning call was for 30 minutes duration and the duties were to support Mr Lyons with
shaving, washing and dressing in clothes of his choice. Assist to the toilet, empty and clean urinal
bottle. Support with making breakfast and carrying to the table. Leave a jug of cold drink to hand.
There is no mention of Mr Lyons having difficulty swallowing or any mention of him needing
supervision whilst he eats.

3"? April 2014:

In line with our company policies and procedures, we conducted our own care needs assessment
and Mr Lyons’ sister was in attendance. It is clearly stated on the front of our assessment form that
no other health/social care professionals are involved in Mr Lyons’ care at this time. We have ticked
the box ‘difficulty with swallowing’, however the recommendation from the sister at the time of
assessment was to try thickener in drinks for 2 weeks. It was not clearly identified where this
information came from. (See Appendix 2)

14" April 2014:

There is a hand written note in the file from FY Mr Lyons’ sister, stating he has to have
thickener added and instructions how to do this. Once again, it is not stipulated where this
information stems from. There is no mention of a special diet or high risk foods.

10th September 2014:

An additional Support Planning document was received from Havering Social Services requesting this
agency provide a 30 minute lunch call, as a result of Mr Lyons being discharged from hospital,
following a fall at home. The tasks were to assist him with toileting, prompt medication and support
with a meal and hot drink. There was no mention of Mr Lyons requiring supervision when eating.

Mr Lyons had been assessed by a speech and language therapist (SALT) in April and June 2014. The
SALT provided recommendations for the management of his swallowing difficulties and these
included providing a list of high risk foods and advice that he should be encouraged to eat slowly;
he should take small bites and his food should be cut into small pieces before serving. The list of
high risk foods included toast.

| heard evidence from Mr Lyons’ sister, P| who confirmed that she had telephoned the
John Stanley Agency to confirm that a SALT assessment had taken place. She could not recall
whether she gave any detail of the recommendations made by the SALT, during the call. She stated
that she left the list of recommendations including the list of foods by the Blue Book. | understand
that the Blue Book is the book used by the Agency carers. It would appear from her evidence that
some of the carers were aware of the need to cut up Mr Lyons’ food.

It is possible that Mr Lyons moved the recommendations and list. | am however satisfied that the
Agency were aware of the need to put in place steps to protect Mr Lyons from the risk of choking
(i) from the information provided to them at the outset of their involvement and (ii) as a result of
the call confirming that a SALT assessment had taken place.

This information regarding the SALT assessment was not passed on to this agency. There is nothing
documented on our computer system concerning a phone call having been received, which would
have necessitated the need for the care plan to be changed. Had we been made aware of an
assessment taking place and specific recommendations being put in place regarding Mr Lyons’ food,
we would have clearly listed this on our assessment paperwork and care plan and informed all carers
who were involved in Mr Lyons’ care at that time. In addition, we would have contacted Social
Services informing them of the change in Mr Lyons’ needs and requested revised paperwork to
reflect these changes and the need for extra time to complete the tasks. The increase for the
morning call would have been required, as it is impossible to carry out all the personal care tasks
already stipulated on the care plan and supervise Mr Lyons’ eating within the 30 minutes allocated
by Social Services. We have no paperwork stipulating that Mr Lyons was at risk of choking and,
therefore, needed to be supervised for all meals.

Notwithstanding the risk of choking, the care plan for Mr Lyons provided only for thickener to be
added to his orange juice. There was no provision for supervision during eating or for his food to
be cut up.

The reason we had made provision for thickener to be added on the care plan is because ||
HE was present during our initial assessment and made this request at that time. Ms Newson
had also placed a hand written note in our Service User Home Notes Folder (‘Blue Book’) on the 14"
April 2014, requesting thickener is added to the juice. There is no evidence documented to say this
had been put in place as a consequence of a report from a SALT assessment.

MATTERS OF CONCERN

1. The care agency were aware of the swallowing difficulties experienced by Mr Lyons and
they had been informed of a SALT assessment having taken place in June 2014

We were aware that Mr Lyons had difficulty with swallowing as a consequence of his sister I
HB forming us during our risk assessment. Our paperwork states that ‘no other health/social
care professionals are involved in Mr Lyons’ care at this time. There is no information documented
that we have been informed that a SALT assessment had taken place.

2. There was no evidence that the care agency had made any attempt to determine the
outcome of the SALT assessment and to put into place steps to protect Mr Lyons from the
risk of choking

As we were unaware that a SALT assessment had taken place, consequently we were unaware that
there was a requirement for us to cut up Mr Lyons’ food. The care plan received from Social Services
on 10" September which asked us to put in an additional visit for lunch, made no reference to the
fact that Mr Lyons’ now needed to be observed whilst eating.

3. Some carers were aware of the need for food to be cut into small pieces. The carer who
attended on the 23’ September confirmed that she was not aware that food needed to be
cut up.

If that is the case, that information was never passed on to this office. All the log sheets (in the
Home Notes Folder) from 7th April 2014 to 22"° September 2014, have been audited and there is no
documented evidence that food had been cut up, or that care workers have waited until he had
finished his food. It would also appear that toast was Mr Lyons’ preferred choice of breakfast, as it is
mentioned on numerous occasions. All care workers are instructed to offer choice and respect
service users’ wishes. Ifa list of high risk foods had been available then ALL care workers would
have been informed and the care plan and risk assessment would have reflected this.

4. The care plan did not provide a management plan to protect Mr Lyons from the risk of
choking. The care plan did not specify that food should be cut up and did not confirm that
Mr Lyons should be supervised.

The care plan did not specify food should be cut up and Mr Lyons should be supervised as we had
not been made aware that a SALT assessment had taken place and that there were
recommendations in place. In our initial assessment on 3rd April 2014, it is clearly stated ‘no other
health/care professionals involved’. At no time had there been any mention from Social Services
that Mr Lyons is at risk from choking so should, therefore, be supervised at meal times. If this
information had been made known to us then we would have contacted Social Services and
requested extra time, as it is impossible to support Mr Lyons with shaving, washing and dressing in
clothes of his choice, assist to the toilet, empty and clean urinal bottle, support with making
breakfast and carry to the table, leave a jug of cold drink to hand and supervise him whilst he ate.

5. The care plan was dated 10" September 2014. The information from the SALT was
available at the time and the author of the care plan should have taken steps to ensure
that the care plan reflected the recommendations from the assessment.

Our care plan dated the 10" September 2014, has the lunch visit entered, however, the tasks are not
listed. We received paperwork from Social Services requesting an increase in care in the form of a

lunch visit for Mr Lyons, as a direct result of him being discharged from hospital, following a fall at
home.

In fact, our Reviewing Officer had telephoned [i in order to make an appointment to
complete the revised care plan, to include a lunch call. She was informed by i” husband
that she was at the hospital with her other brother who was very unwell. It was agreed with her
that we would start the lunch call as per the instructions from Social Services, which were to assist
Mr Lyons with toileting, prompt medication and support with a meal and hot drink. The Reviewing
Officer tried again to contact] however, the brother who was ill, had sadly passed away
and I asked if we could postpone the meeting until after the funeral, which we naturally
agreed to, under the circumstances.

It is important to make clear that at no time whatsoever, had we been informed by either Havering
Social Services or that Mr Lyons was at risk of choking or in need of supervision whilst

eating.

Registered Manager
20.03.15