Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0407, written 15 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 | 15 Oct 2015 |
|---|---|
| Reference | 2015-0407 |
| Deceased | William Tolen |
| Coroner | John Pollard |
| Coroner area | Manchester South |
| 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 TO: Shawe Lodge, 1,Barton Road, Urmston M41 7NL: Podiatrist: 1 CORONER | am John Pollard, senior coroner, for the coroner area of South Manchester 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 7" March 2015 | commenced an investigation into the death of William Gordon Tolen dob 12" January 1933. The investigation concluded on the 14" October 2015 and the conclusion was one of Natural Causes. The medical cause of death was 1a Septicaemia 1b Cellulitis and 11 Coronary Artery Atheroma . 4 | CIRCUMSTANCES OF THE DEATH Mr Tolen was living at Shawe Lodge from the 29" January 2015. On the 10" February it was noted that he had a problem with his legs and the GP attended and cream was prescribed. Thereafter it was also noted that he had a problem with the nail on his left great toe. The podiatrist attended and , inter alia, she removed the toe-nail which she stated was already detached from the toe. This procedure was carried out in the sitting room area of the home. Mr Tolen went on to develop cellulitis in his legs, although this was not apparently directly linked to the removal of the nail. 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. The quality of note recording and keeping at the home fell a very long way short of what might be considered satisfactory. The effect of this was that the member of staff giving evidence was unable to confirm many facts because they were simply not recorded either properly or at all.(Shawe Lodge) 2. The need for the attendance of a podiatrist was, or should have been apparent to the staff at the home, and yet they allowed 5 days to pass without ensuring that their messages had been received, hence there was a delay before Mr Tolen was seen and treated.(Shawe Lodge) 3. The witness from Shawe Lodge confirmed in evidence that the staff did not have any training in relation to dealing with this type of matter and that the nurses were not trained as to the fact that they could and should contact the Clinical manager in such cases. 4. Following this death, there has been no form of investigation by Shawe Lodge to review procedure, training or protocols within the home. (Shawe Lodge) 5. The notes at Shawe Lodge indicated that the nail had been removed from the “right” great toe when in fact it was the left. This was apparently due to a misinterpretation of an abbreviation in those notes. (Shawe Lodge) 6. The details kept in the daily “Diary” at the home were grossly inadequate, an example being “chase up podietry (sic) for William” on the igt February. He was known as Gordon. No-one appears to have pursued this or noted that the podiatrist did not attend until the 24" February. The whole system of notes being kept in a diary, in a separate individual note file, in MDT visits book and in a GP visits book appears inevitably to lead to confusion.(Shawe Lodge) 7. The Podiatrist attended and was left with the patient in the sitting room. The Shawe Lodge staff did not remain and did not offer to assist with his removal to a more suitable location for the procedure to take place. (Shawe Lodge) 8. The podiatrist carried out a procedure in the sitting room. She had to remove food debris and other detritus from around Mr Tolen’s feet before she could put down plastic sheets. This practice rendered both Mr Tolen and other residents at risk of infection and it was wholly inappropriate to carry out such a procedure in this “ 9. Extremely late in the inquest hearing, | was informed by the attending staff from Shawe Lodge, that Mr Tolen was subject to a D.O.L.S order when he was resident there. This information, which subsequently proved to be erroneous, could have been of vital importance.(Shawe Lodge) 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 by 10" December 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 co e Chief Coroner and to the following Interested Persons namely wife of the deceased). | have also sent it to C.Q.C who may find it useful or of interest. 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, aboyt the release or the publication of your response by the Chief Coroner. 15.10.15 John Pollard, HM Senior 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.
Regulation 28 Report- Shawe Lodge- 16 November 2015 1. All staff have received further supervision and training in relation to documentation. This is a process that began in March and improvement is evident in current documentation. Instructions have been added to in relation to your specific concerns. 2. Staff requested a visit from a private podiatrist in relation to a corn on Mr Tolen's right toe. There was no evidence of infection and the visit, although required, was not deemed to be of an urgent nature. It has been requested of all staff that failure to receive a response to a message left should be reported immediately to a senior member of staff. 3. The Clinical Manager's response to your concern about training was intended to indicate that staff did not have training specific to podiatry requests. All nurses are aware of the procedure to follow should they have difficulty obtaining medical assistance. This support is available constantly through an established on call system within the home. 4, Circumstances surrounding Mr Tolen's admission to hospital were discussed by management at the time and staff were deemed to have acted immediately and appropriately in relation to suspected cellulitis . An investigation was carried out at the end of May in relation to actions surrounding the discovery of possible cellulitis at the request of the Safeguarding Team and submitted to them on 2 June. Staff appear to have acted prom iscovery of imflammation to Mr Tolen's left lower leg and when visited b it was not considered to be in need of antibiotic treatment. Staff also acted promptly the next day requesting a further visit due to deterioration and suggesting transfer to hospital.To date the outcome has not been received although we were informed that an inquest was to be held. 5. The notes written by staff at Shawe Lodge did not indicate that Mr Tolen's nail had been removed. This was an entry made by the podiatrist. The subsequent investigation for safeguarding contained an error made by myself when attempting to decipher the shorthand and abbreviation used by the podiatrist. All visiting professionals have been advised that the home will not accept the use of abbreviation and our own staff have also been reminded of this. 6. The diary is used as a communication tool from one shift to the next or as a reminder to themselves of what is required to be done the next day. As it is a document that relates to more than one resident details are kept to a minimum and should refer the reader to the resident's own notes. I would agree however that the notes are too brief and did not contain clear instruction or request. Neither did they contain clear explanation of progress to date. It has been requested of all staff that requests are stated clearly and that progress is recorded rather than ticking the message. The home does not have a GP visit book or an MDT visit book. This information is kept on sheets at the front of the resident daily notes and is intended to provide a quick reference to previous visits thereby removing the need to read through weeks or months of daily reports. These sheets should not, however, be used as a substitute for recording in the daily notes. All details should be entered in full in the daily notes with a brief explanation being entered on the visit record. This has been discussed with all nurses and is being monitored regularly. 7. The podiatrist stated at the inquest that staff were available, and initially present, to help with persuading Mr Tolen to move to another location but that Mr Tolen refused. Mr Tolen was independently mobile and his reasons for not moving were down to choice rather than ability. Whilst Mr Tolen had no issue with having his feet examined he became physically aggressive when it was suggested that he should move. 8. The podiatrist made the decision to examine Mr Tolen's feet in the lounge but this is not the policy of the home whether or not a procedure is planned. Staff have been requested to ensure that all intervention from any member of the MDT is carried out in the resident's own room. If this is not possible, for any reason, the appointment should be rescheduled. 9. Staff from Shawe Lodge did not advise that Mr Tolen was subject to a DoLS authorisation. This claim was made by Mr Tolen's wife and confirmed by her friend. Staff from the home disputed this claim but advised that, due to a delay between authorisations being requested and granted, they could not confirm that one had never been requested without having access to his full notes which were not brought to the inquest. This information was confirmed the next day as requested.
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