Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0419, written 2 Nov 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Nov 2015 |
|---|---|
| Reference | 2015-0419 |
| Deceased | Jean Gillespie |
| Coroner | Alan Wilson |
| Coroner area | Blackpool and Fylde |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
The Alexandra Court Care Home
The Manager/proprietor
110 Victoria Road East
Cleveleys
Lancashire
FY5 3SZ
1
CORONER
I am Alan Wilson, Senior Coroner, for the area of Blackpool & Fylde
2
CORONER’S LEGAL POWERS
I 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 15 May 2015 I opened an investigation into the death of Jean Dorothy Gillespie aged
89 years. The inquest concluded on 28TH October 2015.
The conclusion of the Coroner as to the death was a Narrative verdict:
Jean Gillespie died of bronchopneumonia, the onset of which was contributed to by the
effects of not receiving prescribed medication she required to control the potentially life
threatening condition Myasthenia gravis.
The medical cause of death was:
1 (a) Acute cardiorespiratory failure
1 (b) Bronchopneumonia
1 (c) Myasthenia gravis
2 Senile Multi Organ Involution. .
4
CIRCUMSTANCES OF THE DEATH
Residing at a care home for respite care since 9th April 2015 the last of a supply of Jean
Gillespie’s prescribed medication Pyridostigmine was administered to her on the
morning of 25th April 2015. At approximately 5pm on 26 April 2015 she was observed to
be suffering from symptoms attributable to the condition Myasthenia gravis. She was
taken to hospital but her condition deteriorated and she passed away at 22.26 hours on
8 May 2015.
1
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 inquest heard that a senior member of the care staff with responsibility for
administering medication to residents and for re-ordering supplies of medication
did not know that the deceased suffered from myasthenia gravis, nor was this a
condition she had heard of before.
3.
2. When supplies of the necessary medication were about to expire she did seek
to re-order supplies. When they did not materialise she did not appreciate the
urgency the situation demanded until symptoms became evident.
I am concerned that irrespective of whether this is a care home rather than a
nursing home that staff with responsibility for administering and / or re-ordering
supplies of medication for potentially life threatening conditions are aware of the
conditions and what the medication is prescribed for so that staff can then react
accordingly.
4. Further, consideration of the care home records made no reference to the name
of the condition, the symptoms that can materialise, nor what the prescribed
medication was for. A member of staff previously unfamiliar with this patient who
may have responsibility for administering her medication would not have been
able to familiarise themselves with the necessary knowledge from a perusal of
the care home records and I am concerned there is a risk of future deaths were
this situation to be replicated.
At the conclusion of the inquest, I indicated to the Properly Interested Persons that I
proposed to write to the Trust by way of a report in accordance with the provisions of
paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
[AND/OR your organisation] 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 by 28th December 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 Chief Coroner and to the following Interested
Persons
The family of Jean Dorothy Gillespie
The Coroner’s Society
I am also under a duty to send the Chief Coroner a copy of your response.
2
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.
9
A.A.Wilson
Alan Wilson
Senior Coroner for Blackpool & The Fylde
Dated: 2ND November 2015
3
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.
CG Maria Mallaband Care Group Westcourt, Gelderd Road, Leeds, LS12 6DB email: admin@mmcg.co.uk Tel: 0113 238 2690 Fax: 0113 238 2691 Mr A Wilson Senior Coroner Blackpool and Fylde Coroner’s Office Municipal Buildings Corporation Street Blackpool FY1 1GB 11" December 2015 Re: Jean Gillispie — Regulation 28 Report Dear Mr Wilson | write in response to the Regulation 28 report received following the inquest for Jean Dorothy Gillispie. | can confirm the following actions have been taken to help prevent future deaths. The Senior Care Assistants in the home have received further medication training & Competency assessments, Supervisions have been completed highlighting the importance of ordering, receiving and dispensing medications, following the inquest a further supervision has been completed to reinforce the polices and procedures of medication management. The manager took sole responsibility for managing the medication at the time of the incident to ensure no residents ran out of their medication. The Home Manager completes medication audits to ensure any issues identified can be dealt with swiftly. There are tools available to assist staff with concerns or medications/conditions they are not familiar with i.e. BNF book, external professionals and our internal Quality team. Each member of staff is accountable & responsible for their own actions and how they implement/use the tools & resources available to them. Registered Office: Maria Mallaband Care Group Lid Wesicourt, Gelderd Road, Leeds LS12 6DB ex Tel: 0113 238 2690 Fax: 0113 238 2691 email: admin@mmeg,co.uk ¢ \ INVESTORS Nv, Vv I www.maria-mallaband.co.uk We N PEOPLE Company Number: 03135910 Alexandra Court has a new manager who has introduced handover sheets and medication count down sheets; this will assist the staff to recognise any issues or shortfalls with medication stock control and using the handover sheets to document actions taken or needed will improve communication. Yours Sincerely 1 | Le Tracey Yates Maria Mallaband Care Group
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