Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0090, written 4 Mar 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Mar 2016 |
|---|---|
| Reference | 2016-0090 |
| Deceased | Elsie Raper |
| Coroner | Crispin Oliver |
| Coroner area | County Durham and Darlington |
| Category | Community health care and emergency services related deaths · Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Po Practice Business Manager, Neasham Road Surgery, 186 Neasham Road, Darlington DL1 4YL 2. [EE County Durham and Darlington NHS Foundation Trust, Legal Services, University Hospital of North Durham, North Road, Durham DH1 Grosvenor Park Care Home, Burnside Road, Darlington DL1 4SU CORONER !am Crispin Oliver, Assistant Coroner, for the Coroner area of County Durham and Darlington 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. (see attached sheet) INVESTIGATION and INQUEST On 3" September 2015 | commenced an investigation into the death of Elsie Raper, The investigation concluded at the end of the inquest on 1" March 2016. The conclusion of the inquest was that Elsie Raper died from 1a. Multiple Bone Fractures (of left tibia, left fibula and left femur) treated 1b. Multiple Falls including recent fall on 21 August 2015, Frailty of Old Age and Osteoporosis. She suffered a fall on 10" June 2015, resulting in a fractured tip of femur for which she was treated. The implications of osteoporosis were not appreciated. She suffered further falls when she was admitted to Darlington Memorial Hospital on 11" August 2015 and on 21" August 2015 when she suffered fractures of the left tibia and fibula which could have been, but were not diagnosed until 25" August 2015. She died at Grosvenor Park Care Home, Darlington on 26" August 2015. The overall conclusion was accidental falls causing fractures. CIRCUMSTANCES OF THE DEATH Elsie Raper was born on 6" August 1921. She entered the Grosvenor House Care Home, Burnside Road, Darlington in January 2014. She had a diagnosis of osteoporosis from 2007. She was self-mobilising. She had capacity. She suffered a fall on 10" June 2015. This resulted in a fractured tip of femur. She was treated for this. Osteoporosis is mentioned in her medical notes from the GP's surgery, Neasham Road, at this time. She was admitted to hospital and discharged back to Grosvenor House Care Home on 229 June 2015. She had a further fall on 11" August. There was another fall on 21°" August. In her evidence the Care Home Manager accepted that there was insufficient attention given to the possibility of fractures arising in the light of Elsie's osteoporosis. Elsie received on most days attention including examination on 13" August, 15" August, 17” August, 22™ August and 24" August 2015 from nurses from Darlington Out of Hours Service and Darlington District Nursing. She was examined by a GP from Neasham Road Surgery on 17" August 2015 and 24"" August 2015. She was examined by a Doctor from Bishop Auckland Urgent Care on 23” August 2015.It was on 24" August that she was referred to hospital. She was referred for X-Ray. It was the evidence of her daughter of Elsie Raper, EM that it was she who insisted upon the X-Ray. The evidence of a GP from Neasham Road Surgery was that he accepted that there had been a delay in treating the fractures. The evidence from a Consultant in Emergency Medicine at Darlington Memorial Hospital was that the presentation of Elsie’s leg on 25" August, irrespective of the X-Ray results, made for a likely diagnosis of fractures to the | leg. Elsie’s family members stated that she had been in extensive pain after 21" August 2015. 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) That Elsie Raper, being a patient and being subject to regular visits and examination by GP’s and nurses, suffered a fracture to her left tibia and left fibula probably on 21° August 2015, which remained undiagnosed until the 25" August 2015. (2) During the period 21° — 25" August she was in extreme pain (3) The cause of death included multiple fractures. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you [AND/OR your organisation] 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 29" April 2016. 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. | have also sent it to who may find it useful or of interest. | 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. C.A Oliver, M.A. H M Senior Assistant Coroner County Durham and Darlington
2 responses 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.
Your Ret: 25" April 2016 Crispin A. Oliver M.A. HM assistant Coroner for County Durham & Darlington 29 APR 2016 H.M. Coroners Office PO Box 282 Bishop Auckland Co Durham DL14 4FY Dear Sir, Re: Mrs Elsie Raper — Deceased Grosvenor Park Care Home Burnside Road: Darlington, County Durham. DLI 4su Following the recent conclusion of the inquest into Mrs Raper’s death, we have now received the Investigation Report. The inquest highlighted a need for a response from us regarding details of actions taken since Mrs Raper’s death. I can now confirm that the actions listed below have been duly initiated: 1. 24 Hour Falls Observation Charts: allowing staff to monitor a residents condition more closely after a fall and gives us documentary evidence to support any concerns we may have when contacting external healthcare professionals. 2. A list of all residents with a confirmed diagnosis of Osteoporosis has been completed and is held in the Home for review and reference by the staff team. This allows the team to recognise which residents may have an increased susceptibility to fractures following a fall. 3. Residents Care Plans have been reviewed and rewritten to incorporate the details associated with a diagnosis of osteoporosis and increased risk of fracture. 4. Following a low impact fail for a resident with a diagnosis of osteoporosis the home refers to the Community Matron for review due to the increased risk of fracture. We have discussed these actions with the GP and extended Multidisciplinary Team who have agreed these actions and a willingness to support the team. Yours Sincerely, Au Home Manager A member of the Four Seasons Health Care group of companies Laurels Lodge Limited, Registered Office, Norcliffe House, Station Road, Wilmslow, SK9 1BU Registered In England. Company number. 03138898. Printed on 100% Recyclable Elemental Chiorina Free paper. Manufactured under iSO 14001 & carries Forestry Stewardship Council certification.
Neasham Road Surgery Tel: 01325 461128 Fax: 01325 469123 186 Neasham Road Darlington Co Durham DL1 4YL Practice Business Manager. Operations Manager] www.neashamr ANS. 13" April 2016 Your Ref: CAO/AB/1868/15 Crispin A Oliver M.A H M Assistant Coroner for Co Durham & Darlington HM Coroners Office PO Box 282 BISHOP AUCKLAND DL14 4FY Dear Sir Re: Elsie Raper Deceased Following the recent conclusion of the inquest into the death of Mrs Elsie Raper, we have received the regulation report to prevent further deaths. The inquest highlighted the delay of the diagnosis of fractures sustained. The review in our clinical meetings of 5" February 2016 and 12" April 2016, discussed this fact and outlined the following action points: 1. A fallin an elderly frail person should prompt investigations. A minor trauma may result in a fracture. A prompt referral via an ambulance for assessment (specifically an x-ray) should be initiated without delay. 2. The care plan needs to include any factors to prompt and support this action like history of dementia or osteoporosis. 3. Regular review of contributing risks of falls needs to be assessed and reviewed regularly to implement the right staffing/supervision level and safety equipment (eg Zimmer frames, walking aids, supporting staff, wheelchairs etc) as well as medication reviews which may affect the level of alertness and mobility. We have discussed the issues with the staff at Grosvenor Park Care Home and trust that we can reduce the risk through the measures taken above. Yours sincerely 4 DR ANDREAS RUSS GP On behalf of the Partners of Neasham Road Surgery
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