Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0083, written 6 Mar 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Mar 2015 |
|---|---|
| Reference | 2015-0083 |
| Deceased | Emmeline Hampson |
| Coroner | Alan Walsh |
| Coroner area | Manchester (West) |
| Category | Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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)
NOTE: This form is to be used after an inquest.
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REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. The Chief Executive, Pindy Enterprises Limited, 55 Periwinkle Lane,
Hitchin, Hertfordshire, SG5 1TZ
1 | CORONER
I am Alan Peter Walsh Area Coroner, for the Coroner Area of Manchester West
{ __
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.
INVESTIGATION and INQUEST
On 13" November 2014 I commenced an Investigation into the death of
Emmeline Hampson, 91 years, born on the 7" September 1923. The
Investigation concluded at the end of the Inquest on the 10" February 2015.
The medical cause of death was:
1a) Subdural Haematoma and Intra Cerebral Bleeding from Fall
2) Warfarin Therapy for Atrial Fibrillation.
The conclusion of the Inquest was that Emmeline Hampson died as a
consequence of injuries sustained in an accidental fall exacerbated by a
recognised complication of warfarin therapy.
a[
CIRCUMSTANCES OF THE DEATH
1. Emmeline Hampson died at the Royal Bolton Hospital, Minerva Road,
Farnworth, Bolton on the 6" November 2014.
2. The deceased had a medical history of Dementia, Osteoporosis,
diabetes, Hypothyroidism, Urinary Tract Infection and a history of falls.
She had been diagnosed with Atrial Fibrillation and she had a pacemaker
fitted.
In March 2014 she was prescribed warfarin, which was commenced
when she was an inpatient at the Royal Bolton Hospital, Bolton. She was
referred to the Anticoagulant Service in Bolton and her first contact with
the Service was on the 31% March 2014 to enable her warfarin therapy
to be monitored.
3. Between March 2014 and June 2014 Mrs Hampson had a number of falls
in her own home, as well as four admissions to hospital. On the 14 May
2014 Mrs Hampson was admitted to Darley Court, Bolton which is an
Intermediate Care Unit from the Royal Bolton Hospital, as she required
further rehabilitation and a further assessment of her needs.
4. During Mrs Hampson’s stay at Darley Court it was agreed with Mrs
Hampson and her family that a long term residential placement would
best meet her needs and on the 23 June 2014 Mrs Hampson was
admitted to Hazelbrook Christian Nursing Home, Albert Street, Horwich,
Bolton, which is owned by Pindy Enterprises Limited of 55 Periwinkle
Lane, Hitchin, Hertfordshire, SG5 1TZ.
When Mrs Hampson became a resident at the Nursing Home her mobility
was assessed and she was found to require walking frame support and
one nurse to mobilise having been deemed to be at a high risk of falls.
To address the risk, a fall sensor was placed in her room. The sensor is a
device situated within the room so that when a resident gets out of bed
a sensor alarm would activate and display on call points within the
Home. In addition to the fall sensor Mrs Hampson had a hand held
buzzer to alert staff when she required assistance.
5. During Mrs Hampson’s residence at Hazelbrook Christian Nursing Home
she had a number of unwitnessed falls and on the 1% August 2014 Mrs
Hampson was referred to the Falls Service to carry out an assessment in
relation to Mrs Hampson’s needs to reduce the risk of falls.
Before the risk assessment was conducted by the Falls Service on the
12" September 2014 Mrs Hampson was found to be suffering from a
Urinary Tract Infection and there was an agreed plan for there to be a
further review two weeks later once the Urinary Tract Infection had
cleared.
On the 23 September 2014 the Falls Service contacted the Nursing
Home and the Service was informed that Mrs Hampson had completed
her course of antibiotics for her Urinary Tract Infection and she was
improving on a daily basis with no further fails.
On the 29" September 2014 the Falls Service again contacted the
Nursing Home and was informed that the Urinary Tract Infection had
cleared and there had been no further falls. Accordingly Mrs Hampson
was discharged from the Falls Service at that time and there was no
further contact with the Service by the Nursing Home.
6. On the 4" October 2014 Mrs Hampson had a fall in the Nursing Home
whilst going to the toilet, she was found to have a small cut to her eyelid
with redness to her knee and a finger injury and she was taken by
ambulance to the Royal Bolton Hospital for treatment. There were
further falls on the 12" October 2014, the 13" October 2014 and the
22™ October 2014 culminating in a final fall on the 29" October 2014
when Mrs Hampson was found in the corridor of the Nursing Home
suffering from a head injury.
7. Following the fall on the 29" October 2014 Mrs Hampson was taken to
the Royal Bolton Hospital where a CT scan of her brain showed that
there was an acute on chronic subdural haematoma over the right
cerebral hemisphere in the parietal occipital region and in the left
parietal occipital region. Neurosurgical intervention was deemed to be
inappropriate and on the 1* November 2014 there was a significant
deterioration in Mrs Hampson’s conscious level and subsequently she
deteriorated and died on the 6" November 2014.
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. During the Inquest evidence was heard that
if There was a significant change in Mrs Hampson’s mobility and
general condition from the 4" October 2014.
ii. From the 4 October 2014 there were five falls including the fall
on the 4" October 2014 and culminating in the fall on the 29"
October 2014. There was no review of the falls risk assessment
and no referral back to the Falls Service following any one of the
falls between the 4" October 2014 and the 29" October 2014
even though Mrs Hampson’s condition had changed and there
were recurrent falls.
iif, There were no procedures in place at the Nursing Home in
relation to the review of risk assessments after a fall or after an
obvious and significant change in a resident's condition.
iv. There were omissions in the documentation and record keeping
at the Nursing Home particularly in relation to falls, and changes
in Mrs Hampson’s condition, which were witnessed by members
of her family on a daily basis.
v. The alarm in relation to the activation of the falls sensor placed in
Mrs Hampson‘s room and the handheld buzzer available to Mrs
Hampson were the same so that it was not possible to distinguish
between activation of the falls sensor arising from Mrs Hampson
getting out of bed and Mrs Hampson requesting assistance from
a carer, which may simply relate to a request for a drink.
Furthermore the alarms activated in the resident’s room and an
office used by staff. The office used by staff includes a clinician's
room where staff prepared medications but the volume of the
alarm in the office was insufficient to be heard in the clinician’s
room, so that a member of staff working in the clinician’s room
would not be able to hear the alarm.
vi. The evidence at the Inquest in relation to the fall on the 29"
October 2014 was given by a trained nurse employed by an
Agency who did not appear to be familiar with the documentation
and record keeping particularly relating to risk assessments and
there did not appear to be any training of Agency Staff in relation
to those procedures. The regular use of Agency staff was of
particular concern bearing in mind that the trained nurse from
the Agency would be the senior member of staff and the only
trained nurse to deal with incidents during the night.
vil. The evidence raised concerns that there is a risk that future
deaths will occur unless action is taken to review the above
issues.
2. Irequest you to consider the above concerns and to carry out a review
with regards to the following:-
i. The procedures relating to risk assessments, particularly involving
falls and the review of assessments after an incident, such as a
fall, or a significant change in the condition of a resident.
ii. A review of the procedures in relation to documentation and
record keeping by members of staff.
iii. Training of all staff, but particularly Agency staff, in relation to
documentation, record keeping and risk assessments particularly
after an incident or a significant change in the condition of a
resident.
iv. A review of the alarm system in the Home so that there may be
different alert sounds to distinguish whether the alarm relates to
a falls sensor indicating that a resident has got out of bed or
whether the alarm relates to a request for assistance by use of
the hand held buzzer, which may be relatively minor and not
pose the same risk as a resident getting out of bed. The review
should also take into account the volume of the alarm system,
particularly in the office and the clinician’s room, so that the
alarm can be heard by all members of the staff at all times to
enable the staff to respond immediately to the activation of an
alarm.
6 | ACTION SHOULD BE TAKEN
In my opinion urgent action should be taken to prevent future deaths and I
believe you and your organisation have the power to take such action.
J
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this
report, namely by the 1% May 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.
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following
Interested Persons:-
EE — Mrs Hampson’s Son
HE — irs Hampson’s Daughter
Bolton Council
WNre
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.
6" March 2015 Mr Alan P Walsh
wa
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