Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0259, written 8 Jul 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Jul 2015 |
|---|---|
| Reference | 2015-0259 |
| Deceased | Meryl Parry |
| Coroner | Robert Chapman |
| Coroner area | Cumbria |
| Category | Other 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 THIS REPORT IS BEING SENT TO: 1. EE Director of Adults Social Care, Cumbria Social Services, Cumbria County Council, 15 Portland Square, Carlisle, Cumbria CA1 1QQ 2. Owner and Manager, Green Lane House, Greenhill,Brampton, Cumbria. CA8 1SU CORONER | am Robert Chapman, Assistant Coroner, for the Coroner Area The County of Cumbria 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 On 19" September 2014 | commenced an investigation into the death of Meryl Parry, aged 80. The investigation concluded at the end of the Inquest on 6"" July 2015. The conclusion of the inquest was: The Cause of death was: 1.a. Plastic bag asphyxia The Conclusion of the Coroner was: Mrs Parry was unlawfully killed CIRCUMSTANCES OF THE DEATH Mrs Parry had suffered from memory loss from about 2006 and in 2012 she was diagnosed as suffering from Alzheimer’s disease. She lived with her husband, J Her abilities declined and this coincided with a substantial downturn in Mrs Parry’s own health. In August 2014 atter discussion with Mrs Parry's social worker and her GP, had decided that Mrs Parry should be accommodated in a residential home. He had spent a considerable amount of time looking for the home that he felt would be best able to accommodate his wife. One of the features of her disease was that Mrs Parry tended to wander away from home. It was agreed that on 1" September 2014 Mrs Parry would be assessed by J at the Green Lane House, Residential Home, and that she would stay there for at least respite care whilst had hospital treatment. Mrs Parry was admitted to Green Land House on the 1* September 2014. On the afternoon of 1" September 2014 Mrs Parry managed to leave Green Lane House unobserved, and was found walking into Brampton. She was returned to Green Lane House and a decision was made by IE that it was not going to be possible to safely accommodate Mrs Parry. (EEE clephoned HEB who was too tired to come to collect her, so she was fed, bathed, and put into her night clothes and returned to her home address. This occurred about 8pm on 1“ September. He lephoned a number of residential homes, and no one was able to take his wife that night. He did not believe that Mrs Parry would be happy and able to survive living in a secure dementia unit. He was suffering from heightened tension, anxiety and stress, and he killed Mrs Parry. 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) There appears to be no system in place whereby the managers of a residential home are required to seek advice from Social Services before discharging a resident (2) There is therefore a serious risk that there are no appropriate arrangements in place to ensure the safety and welfare of the resident after discharge. (3) The system for seeking advice from Social Services should apply irrespective of whether Social Services had placed the resident at the home or whether the placement had been a private one. In the latter case it is likely that a social worker will have been aware of, or had some involvement in, the placement. ACTION SHOULD BE TAKEN: Cumbria County Council Social Services should provide general guidance to residential homes in which it is required that if a residential home is considering discharging a resident then before they do so they should seek advice from Social Services so that Social Services can be satisfied that there are appropriate arrangements in place for the safety and wellbeing of the resident after discharge, and the appropriate time for that discharge. This would apply if Social Services had been responsible for placing the resident within the residential home, and also if they had been placed privately without any Social Services direct involvement. Green Lane House That you should provide to Cumbria Social Services confirmation that your procedures have been changed so that you follow the guidance set out above. You should send me a copy of the confirmation that you send to Cumbria Social Services. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by a September 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: lof Arnison Heelis solicitors, as Executors to Mrs Parry's will | have also sent it to the following who may find it useful or of interest: The Cumbria Constabulary (| Diane Wood Chief Executive of Cumbria County Council Legal Department, Cumbria County Council | 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. 8" July 2015 Robert Chapman [SIGNED BY CORONER]
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.
GREENLANE CARE HOMES LIMITED
Residential Home for the Elderly
Greenlane House
Greenhill
Tel; 016977 2345 Brampton
Fax; 016977 2018 Cumbria
4" October 2015
Dear Mr Woodhouse,
1 am writing to you as instructed by R Chapman, HM Assistant Coroner to confirm that our
Discharge Pack has been changed. It now includes the procedure to follow for an unanticipated
discharge, in accordance with your letter dated 4th September 2015.
Please find enclosed a copy.
Yours sincerely,
Manager, Greenlane House
Registered in England and Wales No. 2851017
Registered Office: 6 Brunswick Street, Carlisle, CA] 1PN
Greenlane Care Homes Ltd- (T/A Greenlane House) Updated: 04/10/2015
Greenlane House, Greenhill, Brampton, Cumbria, CA8
1SU
Phone: 016977 2345, Fax: 016977 41221
CP02 - Discharge Pack
Purpose
e To ensure that discharge is administered in accordance with the values of The Home.
Scope
« All discharges of Service Users from The Home.
Policy
e If appropriate (i.e. not breaching data protection rules), all appropriate information will be
supplied to the alternative placement. The information provided must allow the placement to
continue care and support, including medications, without interruption, as well as preserving the
safety of the Service User at all times.
e Administration will be informed of any proposed discharge in time to allow the Service User's
finances to be finalised and final accounts produced by the time of discharge.
e Where discharge could not be anticipated:
Residents must not be discharged without first consulting the Council irrespective of whether
the resident is Adult Social Care (ASC), privately funded, on a temporary or permanent
placement.
Prior to consulting ASC consult the individual, their family member or advocate (as
appropriate), and advise that a referral is being made to ASC.
Contact ASC via the usual route; in working hours to the District Adult Social Care office Duty
Desk, at other times to the Out of Hours team.
Record all discussions and decisions.
No Discharge is to be made without all relevant parties being in agreement.
e Death of a Service User will be notified to the Care Quality Commission.
Procedure
e Use the full discharge pack (attached) in order to ensure that all procedures are carried out,
where appropriate.
{EY Copyright © 2015 Quality Compliance Systems Limited www.ukqcs.co.uk Tel: 0333 4053333 Fax: 0845 2590210
Greenlane Care Homes Ltd- (T/A Greenlane House) Updated: 04/10/2015
Greenlane House, Greenhill, Brampton, Cumbria, CA8
1SU
Phone: 016977 2345, Fax: 016977 41221
CP02 - Discharge Pack
Discharge Notification
This form to be completed and sent to administration, fully completed, on the day of
discharge.
Name of Service User:
Date of discharge:
Discharged to (address):
Reason for discharge (if deceased, include
time and place of death):
Final account to be sent to (name and
address):
Date which room is cleared/to be cleared, if
not today:
If yes, has it now been returned to the
Department of Work and Pensions?
Any other details relevant:
Copyright © 2015 Quality Compliance Systems Limited www.ukacs.co.uk Tel: 0333 4053333 Fax: 0845 2590210
Greenlane Care Homes Ltd- (T/A Greenlane House) Updated: 04/10/2015
Greenlane House, Greenhill, Brampton, Cumbria, CA8
1SU
Phone: 016977 2345, Fax: 016977 41221
CP02 - Discharge Pack
This form completed by:
On (date):
GA Copyright © 2015 Quality Compliance Systems Limited www.ukqes.co.uk Tel: 0333 4053333 Fax: 0845 2590210
Greenlane Care Homes Ltd- (T/A Greenlane House) Updated: 04/10/2015
Greenlane House, Greenhill, Brampton, Cumbria, CA8
18U
Phone: 016977 2345, Fax: 016977 41221
CP02 - Discharge Pack
Discharge Questionnaire
\f you require further short stay respite, would you come back (tick)?
If your answer is no, could you please tell us what you have not liked, as this will help us to
improve our services for future Service User:
Please score on a scale of 1 to 5 your rating of the following, 5 being best, and 1 worst:
GY Copyright © 2015 Quality Compliance Systems Limited www.ukqcs.co.uk Tel: 0333 4053333 Fax: 0845 2590210
Greenlane Care Homes Ltd- (T/A Greenlane House) Updated: 04/10/2015
Greenlane House, Greenhill, Brampton, Cumbria, CA8
1SU
Phone: 016977 2345, Fax: 016977 41221
CP02 - Discharge Pack
Please sign this if you are willing to do so, and indicate whether you are a relative or
Service User. Thank you for your support.
(eis) Copyright © 2015 Quality Compliance Systems Limited www.ukqcs.co.uk Tel: 0333 4053333 Fax: 0845 2590210
Greenlane Care Homes Ltd- (T/A Greenlane House} Updated: 04/10/2015
Greentane House, Greenhill, Brampton, Cumbria, CA8
1SU
Phone: 016977 2345, Fax: 016977 41221
CP02 - Discharge Pack
Discharge to Alternative Placement — Transfer Details
Religion:
Next of kin (NOK):
NOK notified?
NOK telephone number:
Oo
S
®
2
g
g.
EF
NOK address:
Social Worker:
Medication:
Reason for transfer:
Diagnosis continence:
Waterlow score:
Diet and nutrition:
Dressings:
Risk assessment:
Any particular ADL needs:
Signed (state position):
Copyright © 2015 Quality Compliance Systems Limited www.ukqcs.co.uk Tel: 0333 4053333 Fax: 0845 2590210
Greenlane Care Homes Ltd- (T/A Greenlane House) Updated: 04/10/2015
Greenlane House, Greenhill, Brampton, Cumbria, CA8
1SU
Phone: 016977 2345, Fax: 016977 41221
CP02 - Discharge Pack
Discharge Checklist
Action (if appropriate — mark as N/A
if not) (not in any priority order)
Next of kin informed:
Information sent to other placement:
Discharge form sent to administration:
i! ified:
CQC notified of death
All family members notified
All social contacts notified
Social Services and CCG notified:
Department of Work and Pensions
notified:
Hairdresser etc notified:
Aids returned:
Accounts finalised:
Final account settled:
The Home register updated:
Medications returned:
Room cleared:
Benefits books sent on/returned:
Records updated catering:
Records updated notices:
Records updated lists:
Records updated laundry lists:
Records updated medications:
Other Service Users informed:
Questionnaire issued:
Questionnaire returned:
Copyright © 2015 Quality Compliance Systems Limited www.ukacs.co.uk Tel: 0333 4053333 Fax: 0845 2590210
See every Prevention of Future Deaths report matching Robert Chapman, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.