Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0129, written 1 Apr 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Apr 2016 |
|---|---|
| Reference | 2016-0129 |
| Deceased | Lillian Hursell |
| Coroner | Patricia Harding |
| Coroner area | Mid Kent and Medway |
| 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) . REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Ranc Care Homes Ltd 1 CORONER I am Patricia Harding, senior coroner for the coroner area of Mid Kent & Medway 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 15th July 2015 I commenced an investigation into the death of Lilian Hursell, 94 years. The investigation concluded at the end of the inquest on 29th March 2016. The conclusion of the inquest was that Lilian Hursell died as the result of an accident 4 CIRCUMSTANCES OF THE DEATH Lilian Hursell died on 6th July 2015 at Pembury Hospital from pneumonia contracted as a result of immobility contributed to by unstable fractured cervical vertebra occasioned as a result of a fall from bed on 30th June 2015 at Maidstone Care Centre when cotrails had been lowered in order to provide personal care and the provider of that care was not positioned at the bedside so as to prevent the fall occurring 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 mechanism to hold the cotsides (bedrails) in a vertical position comprise a retaining button in a sliding vertical rail which engages with a corresponding hole in a static rail. Whilst this mechanism operates safely when the mechanism is properly engaged which is established by an audible click, staff at the care home had experienced occasions when the cotsides retaining button had not been fully engaged when the cotside had been raised to prevent a resident falling from the bed rendering the cotside unstable and at risk of lowering inadvertently. (2) Nursing and healthcare staff moved a patient onto her back and placed a pillow under her head when the patient had suffered a significant uncontrolled fall onto 1 her face and the extent of her injuries had not been assessed. It was known at the time that this happened that she had suffered a head trauma as she had a bleeding injury to her forehead, she had however additionally suffered a subdural haematoma and had fractures to her cervical vertebra 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 1st June 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Ambulance Service. I have also sent it to Care Quality Commission who may find it useful or of interest. nurse, South East Coast daughter, I 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. 9 1st April 2016 [SIGNED BY CORONER] 2
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.
Ranc Care Homes Limited King George Place 762 Eastern Avenue Newbury Park Ilford, Essex IG2 7HU Tel: 020 8554 5600 Fax: 020 8554 5944 www.ranccare.co.uk Patricia Harding Senior Coroner Mid Kent and Medway 6th May 2016 Dear Madam, Response to Regulation 28: Report to prevent future deaths (1) I am writing in response to the Regulation 28: Report to prevent future deaths (1) to set out the actions taken in response and additionally proposed to be taken following the death of Lillian Hursall. The Matters of Concern are: 1. The mechanism to hold the cotsides (bedrails) in a vertical position comprise a retaining bolt in a sliding vertical rail which engages with a corresponding hole in a static rail. Whilst the mechanism operates safely when the mechanism is properly engaged which is established by an audible click, staff at the care home had experienced occasions when the cotsides retaining button had not been fully engaged when the cotside had been raised to prevent a resident falling from bed rendering the cotside unstable and at risk of lowering inadvertently. 2. Nursing and healthcare staff moved a patient onto her back and placed a pillow under her head when the patient had suffered a significant uncontrolled fall onto her face and the extent of her injuries had not been assessed. It was known at the time that this happened that she had suffered a head trauma as she had a bleeding injury to her forehead, she had additionally suffered a subdural haematoma and had fractures to her cervical vertebra. Having considered the findings of the coroner we have taken the following actions immediately: A programme of re-training in first aid has been commenced and will be completed by the 1st June 2016. The training is delivered via City and Guilds accredited learning and via a competency based workbook for all the care staff, this is monitored for compliance by the Head of Quality and Compliance. A programme of moving and handling re-training has been commenced and will be completed by the 1st June 2016, this is carried out in the blended approach of e-learning and via competency based workbooks for all staff delivering care. A programme of health and safety retraining has been commenced and will be completed by the 1st June 2016. This is been done via City and Guilds accredited training and competency based workbooks which are independently invigilated. A thorough system of bedrail audits has been introduced to ensure all bedrails lock with an audible click into the safety bracket. This entails an audit via the maintenance operative to check for safety and security which is then rechecked by the home manager. Staff have been re-educated in bed rail use in order to ensure the locking mechanism is properly engaged. This was done via a process of direct supervisions. Staff have received health and safety briefings in daily meetings to reiterate the potential dangers of not ensuring bed rails are locked in position. This is recorded via staff meeting minutes and direct supervisions. All staff have been advised that following a fall no person should be moved until a full assessment by a suitably trained person has been carried out. Should the coroner require additional information in respect of the actions taken or planned please do not hesitate to get in touch with me. Yours Sincerely Chief Operating Officer For and on behalf of Ranc Care Homes Limited
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