Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0236, written 22 Jun 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Jun 2015 |
|---|---|
| Reference | 2015-0236 |
| Deceased | Kathleen Eaton |
| Coroner | John Pollard |
| Coroner area | Manchester South |
| Category | Care Home Health 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.
WW PEAKS & PLAINS Housing Trust oe Mr John Pollard HM Coroner Manchester South tT | 2015 Coroner's Court Mount Tabor Street Mottram Street STOCKPORT SK13PA RECEIVED 12 AUG 2015 11 August 2015 Dear Sir Re: Kathleen Eaton (Deceased) Thank you for your letter of 22 June 2015 enclosing your Regulation 28 Report, the contents of which Peaks & Plains Housing Trust (PPHT) has carefully considered. We have provided a response to each of your concerns below but first thought it might be useful to provide you with some background information about the services PPHT provide. Background PPHT operate and provide a number of support services for those who may need it. These packages are provided under PPHT's 'TrustLink' service. Customers can Opt for one or more of a number of packages with each offering a different level of service. One of the packages PPHT can offer is a 'Telecare' service. Telecare services are provided nationally by many different public and private organisations and aim to offer a service which allows individuals to remain independent and in their homes as long as possible. Telecare provides a range of sensory equipment which enables individuals to have greater control of their environment. PPHT were awarded the contract for providing Telecare services in the Cheshire East area in 2010 following a tender by Cheshire East Council. The contract has remained with PPHT ever since. The contract sets out the services which PPHT is required to provide and it is a term of the contract that services provided are done so in accordance with the Telecare Services Association's (TSA) Code of Practice (the Code of Practice). Continued/..... Trading as Peaks & Plains Housing Trust Ropewalks, Newton Street, Macclesfield, Cheshire, SK11 6Q) 0800 012 1311 or 0330 440 9707 trust@peaksplains.org www.peaksplains.org din England No 05 When a person requires Telecare services in the Cheshire East area, the Council carry out an assessment of what services are required for that person. PPHT is then notified and visits the property to install the equipment. At this time there is no contractual requirement for responders to be medically trained. This is mirrored within the Council’s contract and the Code of Practice. The Telecare service is primarily to install and monitor specialist sensory alarm equipment which aids customers to live independently within the home, by alerting PPHT’s monitoring centre of the need for a variety of responses; including a friendly reassuring voice; contact with the next of kin; contact with emergency services or a visit from a PPHT Responder to assess the immediate needs of the customer, Mrs Eaton Mrs Eaton had accessed Telecare services and had been assessed as requiring a monitoring service of two smoke detectors, a carbon monoxide detector, a bed sensor, and a lifeline with pendant alarm. In the event of a smoke detector or carbon monoxide activation, an Advisor within the monitoring centre would try to contact Mrs Eaton via the equipment in her property. If a false alarm could not be established the Advisor would alert the emergency services. In the event of a bed sensor or pendant alarm activation, an Advisor would try to contact Mrs Eaton and where there was no response, the Advisor would contact the next of kin. In the event that the next of kin could not be contacted, a Responder would visit the property. This is what happened in Mrs Eaton's case. When the Responder reached the property, Mrs Eaton had fallen and wanted to be helped into bed. Mrs Eaton was assessed for any injuries and offered an ambulance twice but refused. Our records show that Mrs Eaton had capacity and following assessment after her fall our Responder made the judgement she still had capacity. She was therefore helped into bed as requested. The Responder left a note for Mrs Eaton's carers who were due later that da to let them know vi what had happened. Your Concerns Concern 1 "The Emergency TrustLink Officer has no formal training in assessing medical issues and that her first aid certificate had also expired." Continued/..... Under the terms of the contract with the Council and the TSA Code of Practice, Responders are not required to have first aid training or a first aid certificate. PPHT does however Operate a rolling training programme. The Responder had not at the time of visiting Mrs Eaton had any formal training from PPHT however she was previously trained in first aid having worked in the NHS. ACTION TAKEN: Following the inquest into Mrs Eaton's death, PPHT and the Council have had discussions about amending the terms of the contract and making it a requirement that: (a) first aid training is provided before any Responder can attend; and (b) first aid certificates are obtained and must not be permitted to expire. PPHT will work with the Council to implement these changes as soon as possible. In the event that amendments are not made to the contract, PPHT will be introducing these requirements and expect this to be in place by 31° October 2015. Concern 2 "Ms Wallis had stated that she was unaware of any set policies or procedures in place for assessing and dealing with head injury cases and that there was nothing in writing advising when it was necessary to summon an ambulance" These procedures are not stipulated within the contract and are not a specified requirement of the TSA Code of Practice; however PPHT does have a procedure in place on the action that will be taken when a Responder attends a property. This procedure is an assessment of the customer by the Responder to determine whether or not an ambulance is required. Although the Responder said that she was not aware of a ‘written’ procedure, she had been trained on responder procedures and the procedures were followed in Mrs Eaton’s case. ACTION TAKEN: PPHT invited the ambulance service to visit PPHT to ensure that the assessment procedure Responders follow is fit for purpose. The ambulance service confirmed that it is similar to theirs and acceptable. They also provided their checklist document for assessing customers for us to use in the future. Both this and the written procedure (Appendix 1) have been updated and shared with staff. Managers will be checking this is embedded during discussions with staff at team meetings and in one-to-ones and will also be carrying out spot checks. Continued/..... os ie Page 4/..... Concern 3 "Whether an adequate service can be provided where the distance is 25 miles to travel" The purpose of the Telecare service is primarily there to provide and monitor specialist sensory equipment. A Responder will only be required to attend where the next of kin (or other nominated person) does not answer a call from PPHT once an alarm has gone off and the person does not respond to PPHT's attempts to contact them via the equipment. Under the Telecare service, where the next of kin does answer then PPHT's involvement is to understand the outcome of the situation and offer the next of kin any further support should it be required, such as call for an ambulance. Under the contract, where a response is required we will attend within 45 minutes and this is in accordance with the TSA Code of Practice and the expectation stipulated in our contract with Cheshire East Council. PPHT has trackers in its vehicles and on this occasion, the Responder left PPHT's building at 5.34 am and arrived at Mrs Eaton's house at 5.58am, taking a total of 24 minutes to attend. ACTION TAKEN: The nature of the Telecare service requires a target response time of 45 minutes and PPHT will continue to comply with the terms of its contract and the TSA Code of Practice. We hope that we have provided a detailed response to your concerns. The welfare and health of those who receive our services is extremely important to PPHT and feedback from our customers asserts that the service truly provides a lifeline to customers in their own home. We were saddened to learn of Mrs Eaton’s death and any feedback which may prevent any harm to any of our customers would be very welcome. Yours faithfully JACQUI SINNOTT-LACEY Director of Operations
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive Officer, Peaks and Plains Housing Trust, Macclesfield. CORONER | am John Pollard, senior coroner, for the coroner area of South Manchester CORONER’S LEGAL POWERS | 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 One" February 2015 | commenced an investigation into the death of Kathleen Eaton dob 18" December 1929. The investigation concluded on the 19" June 2015 and the conclusion was one of Accidental death. The medical cause of death was 1a Subdural and Subarachnoid Haemorrhage 1b Recurrent Falls 11. Congestive heart failure vertebra-basilar insufficiency CIRCUMSTANCES OF THE DEATH: | On the 26" January 2015 she fell in the bedroom of her home. She called her emergency carers by use of her alarm. The carer attended , used a blow-up ‘hoist’ (ELK) to raise her into a position where she could be put back to bed. The carer carried out peremptory checks and then left the deceased to await the arrival of her regular carers who were expected some two hours later. She was later taken to hospital where she was found to have suffered damage to and around her brain. 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. The emergency trust link officer employed by Peaks and Plains conceded that she had no formal training in assessing medical issues. In her statement she had said “I am fully first aid trained” yet in evidence it emerged that she had received this training after the date of this death. It would also appear that her earlier First Aid certificate may well have expired 2. She stated that she was unaware of any set policies or procedures in place for assessing and dealing with head injury cases. There was nothing in writing advising as to when it is appropriate and/or necessary to summon an ambulance. 3. The property where the deceased was resident is situated in Disley and | was told it is approximately 15 miles from the base in Macclesfield. | was also told that the officer was able to travel there in 20 minutes in what she had already told me were snowy conditions. | find this hard to believe and wonder whether an adequate service can ever be provided at that geographical distance. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 by17th August 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 namely hm: 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, 22% June 2015 John Pollard, HM Senior Coroner
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