Margaret Metcalfe

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* Stockton-on-Tees. ,
BOROUGH COUNCIL Adult Services

Big plans for the care we provide

Tithebarm

High Newham Road
Hardwick
Stockton-on-Tees

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Thank you for your letter of 14 March 2016 and accompanying report made under the relevant
sections of the Coroners and Justice Act 2009 and the Coroners (Investigations) Regulations 2013
referring to your investigations into the death of Margaret Metcalfe and concerns about the
potential for future deaths from falls.

29 April 2016

Dear Ms Bailey

| am responding on behalf of The Manager, Rosedale Centre, a Stockton-on-Tees Borough
Council facility for the rehabilitation and assessment of adults. First of all ! would like to convey the
sincere condolences of the Rosedale Centre management and staff to the family of Mrs Metcalfe
following her death in November 2015.

Background

Mrs Metcalfe was a client in the Rosedale Centre between 7" October 2015 and 25" October
2015, the day she was transferred back to the University Hospital of North Tees following a fall in
the corridor outside her room. She had been admitted to the Rosedale Centre for rehabilitation
support from the University Hospital of North Tees on 7° October 2016 having been given
treatment whilst in hospital for a fracture to her right neck of femur following an accidental fall at
home. She was allocated Room 8 on the Laurels Rehabilitation Unit with objectives to increase
confidence, develop mobility and support transfers.

Rehabilitation and assessment support at the Rosedale Centre is provided free of charge for up to
six weeks to people requiring this level of support; usually on discharge from a hospital setting but
occasionally to prevent an admission to hospital.

Mrs Metcalfe was described as “out of sorts” on the 9" October 2015 and found to have a Urinary
Tract Infection, which was treated with antibiotics. During her stay, there were two occasions
when Mrs Metcalfe was found by staff on the floor, i.e. on 9" October 2015 and 11" October 2015.
Neither incident was observed by staff. Mrs Metcalfe told staff that on the first occasion she had
put herself on the floor by slipping down the side of the wardrobe. The second occasion was when
she rolled out of bed. On neither occasion did she sustain any injury. At these times the client’s
tisk assessment was checked by the therapy staff and amended accordingly.

Private & Confidential

Ms C. Bailey

Acting Senior Coroner for Teesside
The Coroners Service
Middlesbrough Town Hall

Albert Road

Middlesbrough

TS1 2QJ

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Stockton-on-Tees y
BOROUGH COUNCIL Adult Services

Big plans for the care we provide

During her stay other concerns were being expressed about Mrs Metcalfe by staff, including her
loss of weight, which was assessed by the Health Trust's Dietician and her confusion, which was
assessed by her GP and apart from low blood pressure could find no physical reason for the
confusion. A referral was made by her GP for an assessment to the Community Psychiatric
nursing service on 16" October 2015 and the nurse visited on 24" October 2015.

A Social Care review was held on 22 October 2015 with Mrs Metcalfe’s social worker present
and a decision taken to recommend a 24hr residential care placement.

Technology Support

The Rosedale Centre provides different levels of technology support to assist staff with the care of
people. The Centre caters for a range of people with varying health and social care needs. There
are 44 separate individual bedrooms situated on four units of 10 or 12 beds. Each unit is staffed
24hrs each day with at least two care staff on duty on each unit between the hours of 7.30am —
9.45pm (8 in total) and one waking care staff on duty on each unit during the night (4 in total).
There are additional management and coordinator staff and staff employed to undertake therapy
support tasks. The Centre also employs housekeepers, catering and administrative staff. The
staffing levels meet the requirements of the Care Quality Commission who have regulatory
responsibility for the Centre.

All rooms have access to the “Nurse Call” system, a hard wired call system linking a hand
operated call “button” to four individual sub control panels, one on each unit; and a central control
panel located outside the main office. Each sub control panel and the central control panel receive
information visually and audibly and each bedroom has a light outside the door offering a visual
indication that a call has been made from that room. It is therefore possible to be aware of any call
made by a person from any bedroom at any time.

The person making the call from a bedroom has access to both a short and long cord with the call
button located on the end of the cord. Once made the call can only be cancelled from the point of
contact i.e. in the room the call was made. It is not possible to cancel the calls from either the sub
control panel or central control panel.

All 44 beds at the Rosedale Centre are fitted with a “Bed Sensor”. This is a Telecare Overlay
system which monitors individual beds and therefore people; that when activated raises alerts via
Stockton-on-Tees Borough Council’s 24hour Care Cail control centre to on-site care staff. The
system is configured to raise alerts between the hours of 9pm and 6am, seven days a week. In
the event the person has left their bed and not returned within a 20-minute period, the on-site staff
receive an alert via a mobile phone call from the Care Call centre. It often picks up that a person
has moved to the chair in the room or on occasion has fallen from their bed.

An additional service known as the “Care Assist” system was introduced in May 2013 at the
request of occupational therapy staff for people assessed as at risk of falling and requiring a 24hr
monitoring service. This is a separate sensor which replaces the Telecare Overlay. A pilot
scheme carried out in different care homes had already shown reductions in the number of people
falling using this system. This additional equipment provides a bespoke package for an individual
person, Those people determined at higher risk have their Bed Sensor deactivated from the
Telecare Overlay and routed to a Care Assist pager.

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Stockton-on-Tees .
BOROUGH COUNCIL Adult Services

Big plans for the care we provide

The Care Assist system offers linked bed and chair sensors in a bedroom, connected together to a
signalling device known as a universal sensor. When the bed or chair sensor is activated it uses
the universal sensor to send a signal to a portable pager. Individual Care Assist devices are fitted
by the Council's Care Call installer. The device sends a signal to the pagers which omit a bleep
and vibrate to alert the staff member of the exact location the alert is from. All alerts are date and
time stamped giving the sensor ID number and person's name and room number.

The Council's Care Call service has an equipment database, which enables tracking of where
equipment is located by its serial numbers. They use log sheets completed by the installer for
every installation.

The Care Assist pager equipment works using a rechargeable battery. It will work for up to 12
hours on one full charge. Each pager requires a period of 2-3 hours of charging each day and
failure to top up the pagers charge fully will result in the pager not working properly. The pagers
require careful handling and are not shock or water proof. The pager stores the alerts of the last
256 events received and it is possible to retrieve the data using a PC connected to a Care Assist’s
USB port.

Mrs Metcalfe’s technology support

Mrs Metcalfe was allocated Room 8 in Laurels unit. On admission she was shown how to operate
the Nurse Call system and had the Bed Sensor available. Following the two occasions she was
found on the floor it was assessed by the Therapy staff that having a Care Assist system installed
would help reduce the risk of a fall. From available records held by Care Call the Care Assist
equipment was installed on 11" October 2015 at 5.30pm by Care Call personnel. On 17” October
and 18" October 2015 Care Call staff visited to reposition the universal sensor.

Fall event 25" October 2015

On 25" October 2015 at 4.30am Mrs Metcalfe was found on the floor of the corridor outside her
bedroom. The night staff member was alerted to the sound of Mrs Metcalfe falling to the floor. Her
incident report indicated she had sustained injuries. A call was immediately made to the 111
service for advice and an ambulance was subsequently requested. At 6.30am the ambulance
arrived and Mrs Metcalfe was taken to the University Hospital of North Tees Accident &
Emergency Department and thereafter admitted to hospital.

An internal investigation has been carried out by the Manager of the Rosedale Centre based on
the Coroner’s Report of 14" March 2016. The focus of the investigation was the fact the fitted Care
Assist system did not alert the night staff member to Mrs Metcalfe leaving her bed. Checks have
subsequently been made on the Care Assist equipment to see if a record could be retrieved for the
25" October 2015. Unfortunately the data information for that date is no longer available on the
device as it had over written the 256 events activation memory.

Evidence from the staff member on duty at the time of Mrs Metcalfe’s fall was given some four
months after the event. Unfortunately at the time of the accident only limited notes of the incident
were recorded in the staff report book. Details of the activity leading up to the point Mrs Metcalfe
was found on the floor have been difficult to recollect. The fact Mrs Metcalfe was able to leave her
bedroom without the Care Assist pager going off may be down to the battery not having been
charged properly i.e. for the required length of time. We know from the guidance that failure to top
up the pager’s charge fully will result in the pager not working properly.

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Stockton-on-Tees .
BOROUGH COUNCIL Adult Services

Big plans for the care we provide

Subsequent Actions Taken
In response to your request that action be taken to prevent future deaths from falls the following
actions have been taken and a written procedure implemented.

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The four Care Assist pagers available within the Rosedale Centre have been fully checked
alongside their separate charging units.

. The charging units have been moved from the kitchen to the main office to allow for

management oversight of the equipment.
Each of the four Care Assist pagers has been re-labelled clearly to identify which unit it is
allocated to and which charging system it belongs to.

. Each Unit Manager has been reminded about the Care Assist procedure and have

discussed with team members the procedure.

Each person will be risk assessed by the Therapy Team to identify who will be allocated a
Care Assist unit.

Staff will be reminded by the Therapy Team of the need to be extra vigilant and give special
instructions to minimise risks until Care Assist equipment is fitted.

At the request of the Therapy team the SBC Care Call team will fit each Care Assist system
and check it is functioning appropriately.

At the start of each shift staff are responsible for checking which bedrooms / people have a
Care Assist unit fitted to the bed/chair. This is covered on the staff handover sheet used for
transferring information between shift changes.

At the start of the shift staff responsible for the Unit will agree who is to carry the Care
Assist pager unless it is the night staff member who will always carry the pager (subject to
Care Assist being used for any person).

The staff allocated the Care Assist pager are to ensure it is re-charged during periods when
people are out of their bedroom (i.e. in the dining / lounge areas).

A record of this will be made by the responsible staff member in the daily care record.

The staff allocated the Care Assist pager are to ensure it is with them at all times and
handed over to a colleague when they leave the unit.

During the time a person is in their bedroom and Care Assist is being used staff are
responsible for checking the Care Assist unit is working.

Staff responsible for the Care Assist pager are to make appropriate notes in the care
records.

Staff are required to respond appropriately and in a timely manner to alerts being triggered
to offer assistance to the person.

Any problems identified with the Care Assist pager will be reported to the Duty Manager
immediately and documented.

Each individual person’s Care Plan and Kardex record will document the use of the Care
Assist equipment.

The Manager has an audit process in place to check the Care Assist equipment on a
monthly basis.

Clearly steps are being taken by the Rosedale Centre to use available technology to assist staff in
receiving timely information as to the movements of people identified to be at risk. The equipment
being used is not something that can guarantee immediate action by the staff even when alerts are
notified. Staff on duty have a responsibility for all people on the unit they are allocated. Generally
staff are supporting people with a full range of daily personal care tasks and can be called upon at

* Stockton-on-Tees ,
BOROUGH COUNCIL Adult Services

a : Big plans for the care we provide

any time to provide assistance. There are times when people are required to wait for staff to be
available. This is especially so during the day time shifts but equally staff can be busy during the
night time ensuring people are appropriately assisted in accordance with personal wishes.

| hope this report and details of the actions taken will provide assurance that everything is being
done to support people at risk of falling. We take our responsibilities seriously and work with
people to encourage maximisation of their independence. This process requires regular
assessment and risk management.

Yours sincerely

ia

Service Manager - Reablement

Cc [ERB- Rosedale Manager
HE Assistant Director (Adult Social Care)