Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0122, written 29 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 | 29 Mar 2016 |
|---|---|
| Reference | 2016-0122 |
| Deceased | Pamela Thurston |
| Coroner | Johanna Thompson |
| Coroner area | Norfolk |
| 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 (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. PY Manager, Cedar Care Home, Yelverton, Norwich NR14 7PB 2. Caring Homes Healthcare Group Limited, Bradbury House, 830 The Crescent, Colchester Business Park, Colchester, Essex CO4 9YG CORONER lam JOHANNA THOMPSON, Assistant Coroner, for the coroner area of NORFOLK 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. INVESTIGATION and INQUEST On 13 July 2015 | commenced an investigation into the death of PAMELA JOYCE THURSTON aged 78. The investigation concluded at the end of the inquest on 29 February 2016. The conclusion of the inquest was accidental death due to 1a) Bronchopneumonia; 2. Alzheimers Disease. CIRCUMSTANCES OF THE DEATH Mrs Thurston died at Norfolk and Norwich University Hospital on 7 July 2015 after choking on some toast she was given at Cedar Care Home in Yelverton, Norfolk two days earlier. . 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. — Mrs Pamela Thurston was a resident at Cedar Care Home in Yelverton. She suffered from Alzheimers’ dementia and required prompting in order to eat meals and also supervision in doing so. Approximately two weeks prior to her death, Mrs Thurston was found to have stored prune stones in her mouth and had to be encouraged to spit them out. This was reported to the Care Home Manager and thereafter she was given prunes with stones removed. Her care plan was not altered, but a note was made for the chef to this effect. The Care Home procedure for checking that residents had been fed at mealtimes was that the chef would tick off the residents on a list kept in the kitchen. The residents were given their evening meal at approximately 5pm, and breakfasts were served from approximately 8am onwards following the staff handover at that time from night to day shift. : On the morning of 5 July 2015, Mrs Thurston had awoken early as was her tendency, and was sitting in the care home conservatory. At approximately 11am, one of the staff became aware that she had not been given any breakfast and a decision was made to give her some toast. This was given to Mrs Thurston who proceeded to eat the toast so quickly that it became stuck in her airway which caused her to choke. Attempts were made to remove the toast when the attention of the staff was drawn to this by another resident. The nurse on duty was in a position to observe Mrs Thurston, but did not directly supervise her in eating the toast. The nurse was unable to remove the toast from Mrs Thurston's airway. Her subsequent attempts at CPR were unsuccessful, and heart rhythm was not restored until the arrival of paramedics. Mrs Thurston developed bronchopneumonia as a consequence of the choking incident, and subsequently died on 7 July 2015 in hospital. It appears that Mrs Thurston ate the toast she had been given too quickly as a consequence of being hungry, having had no food since the previous evening approximately between 5pm and 6pm, being a period of around 17 hours. When given the toast, she was left to eat this without direct supervision. She choked on the toast, and died in hospital two days later. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and 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 31 May 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 and to the following interested persons: I have also sent it to: « Care Quality Commission e Heaithwatch Norfolk e Executive Director of Adult Social Services, Norfolk County Council 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. : Dated 29 March 2016 : SIGNED: Cole. Prohanna Thompson
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.
By email only: norfolk@coroner.norfolk.gov.uk ge eH8 tik CARING HOMES Johanna Thompson Assistant Coroner for Norfolk The Coroner's Office * 69-75 Thorpe Road Norwich NR11UA 20" April 2016 Dear Ms Thompson Re: Regulation 28: Response to Report to Prevent Future Deaths We refer to your Report to Prevent Future Deaths dated 29" March 2016 following the inquest into the death of Mrs Pamela Thurston. Please accept this letter as our response to your Report (“Response”) which notes the action | Caring Homes Healthcare Group Limited (“Group”) has taken, and intends to take, in respect of the concerns you raised in your Report. On 8 April 2016 Frank Cummins, Clinical Director, sent a Memorandum to the Home Managers of all the Care Homes In the Group, along with copies to the Group’s Regional Managers and Head of Operations. The Memorandum relates to ensuring meals are given in a timely manner and your concerns were explained. The Memorandum notes that whilst service users are to be given as much cholce as possible in relation to when their meals are to be served, caution should be taken if a service user has not eaten for a significant period of time due to them missing core meals or snacks which may make them more prone to eating quickly which could put them at an increased risk of choking. It is noted that any risk is Increased where a resident has a significant cognitive or swallowing deficit. Staff have been asked to: 1. Pay particular attention to completing appropriate choking risk assessments for service users and ensure that all staff, including kitchen staff, are fully aware of any service users who may have a compromised swallowing reflex 2. Ensure any service user who may be showing the symptoms of a compromised swallowing reflex are referred to SALT in a timely manner and that the actions SALT prescribe are implemented and that all staff are aware of the recommendations (should staff experience any difficulty in gaining timely advice from the local SALT teams, Mr Cummins should be contacted who will correspond with the SALT Team to try and expedite the matter) Caring Homes Group Tel: 01206 224 100 Canng Hives Healicae Oreup Lined Bradbury House, 830 The Crescent Fax: 01206 224 198 Colchesler Business Park, Colchester, Essex CO4 9YQ vaww.caringhomes.org, ected in Cryfard No, OGIBTSAT Iaty House, B30 Iles Grascent, wb, Colctnsies, Ese C04 BY. : a Hospitolty 3, Ensure that snacks'are available for service users between core meals and that such snacks are encouraged where a period of over eight hours has passed since a service user last ate 4. Ensure an appropriate risk assessment is undertaken and a referral made to SALT where ‘a service user has been known to hoard foodstuffs in their mouth 5. Ensure a tick list is in the kitchen area which documents the time a service user is served @ core meal in the Home. Where it is noticed that a significant period of time has passed between meals for a service user (eight hours or over), or where a service user has missed a meal, direct observations of the service user should be maintained whilst the service user is eating their meal or snack, The person in charge must designate a member of staff to undertake the observation and this should be documented in the service users notes 6. Where a service user has compromised nutritional intake, a record of foods served, the time and the amount taken should be maintained as is usual procedure. The Home Managers have been asked to discuss the Memorandum with their staff team via team meetings or other appropriate method, such as a shift handover. The Group’s Regional Managers have line management responsibility for a number of Homes within the Group. The Regional Managers have been asked to discuss the matters with the Home Managers on their next monthly visit and will also sample staff knowledge. As part of our clinical governance the Regional Managers undertgke a monthly visit to each Home they are responsible for and complete a Senior Manager Monthly Report (SMMR). The SMMR covers a range of matters in order to determine if the Home is complying with the required standards and the Group’s policies and procedures. The SMMR was amended on “18 April 2016 following discussion at the Group’s Clinical Risk Committee to include a requirement for Regional Managers to monitor Homes’ adherence to the Memorandum moving forward. The first SMMR to include the amended area will be undertaken during May 2016. The Group’s Heads of Operations line-manage the Regional Managers and review the monthly audits to ensure that the Regional Managers are undertaking the required checks. The knowledge and implementation of the Memorandum will be monitored throughout the “management structure of the Group, as noted above, and should any further action be necessary then the Group will put into place the required steps. Thank you for your Report and we trust that the above addresses your concerns adequately. Yours sincerely Karel? tacts, Managing Director Caring Homes Group Tel: 01206 224 100 Rede Enea Coren Bradbury House, 830 The Crescent . Fax: 01206 224 198 Registered Oitice. Braduwy Hove, B30 Iie Crescent, Colchester Business Park, Colchester, Essex CO4 9YQ Wwww.caringhomes.org Colchester Business Park, Co'chestis, Essex C04 9¥Q, eN 1s0 9001 Realstered
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