Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0266, written 10 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 | 10 Jul 2015 |
|---|---|
| Reference | 2015-0266 |
| Deceased | Dorothy McDermott |
| Coroner | Simon Nelson |
| Coroner area | Manchester North |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORTTO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Department of Health 2. Rochdale MBC 3. Pennine Care Trust 4. Littleborough Care Home CORONER I am Simon Nelson, Senior Coronerfor the Coroner area of Manchester North 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, ofthe Coroner’s and Justice Act 2009 and Regulations 28 and 29 ofthe Coroners (Investigations) Regulations 2013 3 INVESTIGATION and INQUEST On the 1th0 February 2015 I commenced an investigation into the death of Dorothy McDermott for whom the cause of death was confirmed at Inquest as being that of la) Septicaemia, lb)Decubitus Ulcer / Bed Sore with Hypertension and Urinary Tract Infection, whilst not causative of death, being contributory factors under 2. At an Inquest convened on the 2nd July 2015 the following conclusion was made — ‘Against a background of increasing immobility and susceptibility to urinary tract infections, Dorothy McDermott was at high risk of developing pressure sores. On the 1th7 January 2015, having fallen three times that day, she was admitted from home to emergency respite care where she remained until the 2th6 January. She was not examined when attended upon by a GP on the January and subsequently opportunities to examine her sacrum were missed by reason of inadequate training of care staff. The evidence does not show when the Grade 4 pressure sore developed but more likely than not, it would be over a number of days prior to the 2th6 January on which date a visiting District Nurse was alerted to concerns raised by care staff by which time Mrs McDermott was already in extremis. She was admitted to Fairfield General Hospital where she died during the early hours ofthe 2th7 January 2015’. 4 CIRCUMSTANCES OF DEATH As above 5 CORONER’S CONCERNS During the course ofthe 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: Dorothy McDermott was 80 years old. She had been housebound for 234 years. She had been diagnosed with a urinary tract infection and was confused. On the 1th7 January 2015, she had fallen three times whilst at home. Paramedics advised a rapid response but they finished at 5.3Opm. Mrs McDermott required a place of safety. Following discussions between the Local Authority’s emergency duty team and the out of hours service for the district nursing team, emergency respite care was arranged at the Littleborough Care Home to which Mrs McDermott was conveyed during the early hours of the 1th8 January. It was envisaged that Mrs McDermott would be reassessed on the 1th9 January. The Littleborough Care Home offered residential but not nursing care. Care staff at the home were not trained in either the examination for or care of pressure sores. That placement was inappropriate. The rationale for that decision was one of availability with the facility of a ground floor bedroom which had been newly decorated. Whilst appreciating that the decision to procure respite care was made ‘out of hours’ the overriding concern given the extent of Mrs McDermott’s vulnerability should have been to obtain a suitable placement which guaranteed a place of safety. Whilst not wishing to be prescriptive, formal Guidance is required to as to ensure that vulnerable individuals are appropriately placed by the Agencies involved. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe each ofyou respectively have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 4th September 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the ChiefCoroner and to the following Interested Persons namely: 1. The Department of Health 2. Rochdale MBC 3. Pennine Care Trust 4. Littleborough Care Home I am also under a duty to send the ChiefCoroner a copy ofyour response. The Chief Coroner may publish either or both in a complete or redacted or summary from. He may send a copy of this report to any person who he believes may find it usefulor 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 ChiefCoroner. 1th0 July 2015 Signed: Date:
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