Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0398, written 5 Oct 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Oct 2015 |
|---|---|
| Reference | 2015-0398 |
| Deceased | Peter Furness |
| Coroner | John Gittins |
| Coroner area | North Wales (East and Central) |
| Category | Care Home Health 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Nant y Gaer Hall Nursing Home, Nant y Gaer Road, Llay, Wrexham 1 CORONER lam JOHN ADRIAN GITTINS, senior coroner, for the coroner area of North Wales (East and Central) 2 | 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. 3 | INVESTIGATION and INQUEST On 16" of October 2014 | commenced an investigation into the death of Peter Scott Furness then aged sixty six. The investigation concluded at the end of the inquest on the 30' of September 2015. The conclusion of the inquest was Accidental Death, the medical cause of death being 1(a) Choking on a Latex Glove (b) Dementia. 4 | CIRCUMSTANCES OF THE DEATH 1. The Deceased, who had been diagnosed with Frontal Lobe Dementia, was a resident at the Nursing Home which provides care for persons with dementia. 2. He was known to be at risk of placing non-edible items in his mouth and had been observed doing so on a number of occasions. 3. Although risk assessments had been undertaken he collapsed on the 13' of October 2014 and was verified dead at the home at 12.32 hours. 4. A Post Mortem established that he had choked on a latex glove and two further gloves were found in his stomach which had been ingested previously. 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. — The Registered Individual responsible for the care home and the current Manager both acknowledged that within current systems and protocols operating at the home, there is no documented process by which incidents or concerns are escalated so as to result in a multi disciplinary team meeting aimed at reviewing the risk assessments and care plan relating to the vulnerable person within their care. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation has 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 by 30!" of November 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Person ELV icow 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. [DATE] 5" October 2015 [SIGNED BY CORONER] Spee
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.
NANT Y GAER HALLS John Gittins North Wales Coroner Ruthin LL15 1YN Date: 27-10-15 Re: Regulation 28 Dear Mr John Gittins, In order to fully comply with the regulation 28 we have addressed our alert system. This will alert all staff to changes in our residents’ physical conditions and their behaviours. The new system is self- explanatory (please see copy’s sent - initially a simple alert form is completed by whoever first identifies the concern; this is then evaluated by the qualified nurse in charge and is escalated by the nurse (please see copies sent). This process gives clear instruction throughout the alert process and will inevitably reduce risk and involve the wider disciplinary team immediately if necessary. This remains a work in progress and it will be evaluated and amended to what is working and what is not. All staff have undergone a training session and undergone a supervision on the changes. The new system of raising an alert is supported by posters placed around the building for family’s and visitors to be aware of how we deal with concerns and alerts. (Incidents and accidents are also covered within the alert process and form part of the new policy). | have put together the policy and alert/incident processes and have included flow charts for all staff, alert and incident forms, new handover sheets with 7 day follow up and a new alert poster. All staff have signed to say they have read and understood the policy and alert procedure. Two red alerts files have been developed for both sides of the home so that staff can easily report and follow up on all concerns. Please contact me if you require any further information. Yours sincerely, Graham Allen Responsible Individual Nant-Y-Gaer Hall Ltd Nant-Y-Gaer Nursing Home, Nant-Y-Gaer Road, Wrexham, LL12 OSL Telephone: 01978 852 672, Fax:01978 853 486, Website: www.nant-y-gaer.co.uk, E-mail: nant-y-gaer@tiscali.co.uk Company Reg: 539 7829
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