Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0161, written 25 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 | 25 Apr 2016 |
|---|---|
| Reference | 2016-0161 |
| Deceased | Marjorie Wood |
| Coroner | Joanne Kearsley |
| Coroner area | Manchester South |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Kingsley Care Home Suk Cutters louse, Schoo! Road, Lowesiol:, Sufiik. NK33 GNA rley Care Home Road, 1 | CORONER I am Joanne Kearsley Area Coroner for Manchester South 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 the 18th April 2016 I concluded the Inquest into the death of Marjorie Wood date of birth 22.08.1918 who died on the 02.12.2015. The cause of death was 1a)Bronchopneumonia 2) Advanced Alzheimer’s Dementia and CVA I recorded a natural causes conclusion. 4 | CIRCUMSTANCES OF THE DEATH The Court heard evidence that the deceased had a history of dementia and was residing at Timperley Care Home. She had been found deceased at the care home on the 02.12.2015. The death was reported to HM Coroner as she was said to be subject to a Deprivation of Liberty Safeguarding Application (DOLS). An Inquest was opened and evidence requested from Timperley Care Home. Several requests for evidence were ignored by the Care Home so a full hearing had to take place. At the Inquest the Manager EE was unable to confirm whether in fact the deceased was subject to a DOLS application as Timperley had no information from the Local Authority as to whether this had been authorised. No efforts had been made to contact the Local Authority to obtain this information by the Care Home. They did not know whether the deceased was or was not subject to a DOLS or ; whether this made any difference to the care and treatment she required. A DOLS application had in fact been in place since August 2015. CORONER'S CONCERNS The concerns noted by the Court during the course of the Inquest are as follows: Whilst there was no evidence in this case that the lack of clarity or knowledge in this particular case made a difference to the deceased, it is important that there is a full understanding of the legal status of an individual who is in a care home as this may impact on their care and treatment needs. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 20.06.2016. 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely, the family of Mrs Wood 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. 25.04,2016 Joanne Kearsley Area Coroner
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.
< Kingsley aga du verence Kingsley Healthcare Group Silk Cutters House, Schoo! Road, Lowestoft, Suffolk, NR33 9NA Joanne Kearsley Area Coroner Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG kingsleyhealthcare co.uk Se Dear Miss Kearsley, reff Regulation 28 Report to Prevent Future Deaths following the inquest into the death of Marjorie Wood who died on the 02.12.2015. | ara writing to you to respond to the concerns raised by your investigation into the circumstances surrounding the death of Mrs Wood. Kingsley Care Homes takes very seriously it’s responsibility to ensure that there is a full understanding of the legal status of individuals within our care homes. Our Deprivation of Liberty Safeguards Policy and Procedure is used to guide staff in conjunction with our Mental Capacity Act 2005 Policy and Procedure and local guidance from the relevant supervisory body. These documents were in place in Timperley. An excerpt of our policy is detailed below Deprivation of Liberty Safeguards Policy and Procedure Purpose . _« To comply with The Deprivation of Liberty Safeguards (DOLS) regulations, which are an ~ amendment to the Mental Capacity Act (MCA) 2005 e To prevent breaches of the European.Convention of Human Rights. “The safeguards provide a framework for approving the deprivation of liberty “for people who lack the capacity to consent to treatment or care in either a hospital or care home that, in their own best interests, can only be provided in circumstances that amount to a deprivation of liberty.” The safeguards legislation contains detailed requirements about when and how deprivation of liberty may be authorised. it provides for an assessment process that must be undertaken before deprivation of liberty may be authorised and detailed arrangements for renewing and challenging the authorisation of deprivation of liberty.” (Dept. of Health 2008). BF > a Kingsley Healthcare 1s a trading aare for Kingsley Cars Homes Limiter! (Reg. No. 4446972), Regai Healthcare Properties Linuted (Reg. No 4767494), Country Retirement & Nursmg Homes Limited (Req Au, 379955), Alfpea Healthcare Limvtes (Reg. No. 6321545), Althea Healthcal+ Properties Limited (Reg. No. 6368379), Hestia Healthcare Limited (Reg. No. 6321543) 4i! compatues regisie#red in Engiand Registered Office: Silk Cutters House, Schoo! Road, Lowestoft, Suffalk, NR33 SNA. Scope e Anyone dealing with people aged 18 year or over who has a mental disorder and who lacks the ability to give consent, who may be deprived of their liberty Policy e The Deprivation of Liberty Safeguards Code of Practice, published by the Ministry of Justice, will be followed in respect of all Service Users. A link to the Code of Practice can be found at the end of this document. @ The Deprivation of Liberty Safeguards - Forms and Record Keeping Guide for Managing Authorities ir: England (Hospitals and Care Homes) will be used to manage DOLS. A link to these forms can be found at the end of this document. e This policy should be read in conjunction with the following policies (where applicable): o Supervisory Body/Local Authority Policy and Procedure. o Mental Capacity Act 2005 Policy and Procedure Procedure e Good practice indicates that the care home should take reasonable steps to try and avoid a deprivation of liberty occurring. These steps include o Effective Care Planning that is reviewed regularly; © Involvement of the Service User’s family in decision making, © Exploring alternative and less restrictive ways of providing care consistent with protecting the person from harm; o Assessing the person’s capacity to make decisions about their care e Where a Service User may be being deprived of their liberty, the managing authority has responsibility for applying for an authorisation of the deprivation. In the case of the Service User being in an NHS hospital, the managing authority is the NHS hospital. In the case of the Service User being in a care home or private hospital, the managing authority is the person registered as manager under part 2 of the Care Standards Act 2000. The managing authority should apply to the supervisory body for the area in which the person ts ordinarily resident. ® tn England and Wales, for people in care homes, the supervisory body is the local authority For people in NHS hospitals in England the supervisory body is also the local authority. For people in hospitals in Wales, the supervisory body is the Local Health Board in the area where the hospital is situated. In applying for an authorisation the care home or hospital should use the forms and procedures produced forthe purpose of application and management of a Deprivation of Liberty Safeguard authorisation which are contained in The Deprivation of Liberty Safeguards - Forms and Record Keeping guide for Managing Authorities in England (Hospitals and Care Homes) which can be fourid in the Useful Documents section of the QCS system (in your Quick Links box), A recent review of these forms has reduced the number of forms necessary and these can be found at the link below. These revised forms include a new form for informing the 1A in the event of a death. | ° The managing authority must hy a written record of each application, reasons for the request and authorisation. This should Pe recorded centrally within the home and in each individual's care plan. ~ ® The managing authority should tell the Sovice User's family, friends and carers, and any Independent Mental Capacity Advocate (if there is one already involved) that it has applied for Kingsley Healthcare is a trading name tor Kingsiev Care Homes imited (Reg, No. 4446972), Regal Healthcare Properties Limited (Reg. No. 4767494), Country Retirement & Nursing Homes Limited (Reg No 3790953), Aither healtheure Linated ;Reg. No. 6321 545), Althea Healthcare Properties Limited (Reg. No 6368379). Hestia Healtheare Limited (Reg. No 6321543} Ali corpgans registered ut. England. Registered Office: Silk Cutters House, Schoo! Road, Lowestoft, Suffolk, NR33 9NA, an authorisation, unless it is impractical or impossible to do so, or it would be undesirable in the interest of the Service User's health or safety e |fastandard authorisation is given, the supervisory body must appoint a relevant person's representative (RPR) to maintain contact and support the person. The managing authority must make sure the person and their RPR understand the nature of the authorisation. e Where someone dies whilst subject to a Deprivation of Liberty authorisation, the care home or hospital should report the death to the Coroner, in accordance with the Coroners and Justice Act 2009 and subsequent guidance given by the Chief Coroner in December 2014 regarding deaths of people deemed to be in state detention. There is a link at the end of this policy to statutory forms which includes a form for reporting a death to the Coroner. There is also a link to the Chief Coroner’s guidance regarding people subject to Deprivation of Liberty Safeguards Ms Cank had previously completed training in relation to MCA and DoLS. She has undergone supervision with her line manager in respect of the concerns raised by your investigation and is due to undertake further training. Timperley had failed to follow policy and keep a written record of each application, reasons for the request and authorisation. This information is now checked during audits of the home and is available on shared file to line managers. | hope that the information provided offers assurances that the findings of your investigations and the areas you have highlighted for the prevention of future deaths have prompted action and been the focus of our continued commitment to providing quality care for individuals living in our homes. Yours sincerely, 4. Lovo! Director ef Service Quality Kingsley Care Homes Kingsley Healthcare is a trading rirne fo: Kingsley Care dume: Limited (Reg No 4446972), Regal Healtlicare Properties Limited (Reg. No. 4767494), Country Retirement & Nursing Homes Limited (Reg Nc. 3790953), Althea Heaithcare Limited ‘Reg. No, 6321545), Althea Heaithcare Properties Limited (Reg. No. 6368379), Hestia Healthcare Limited (Reg. No 6321543:. Ali cornpanies registered in England Registered Office: Silk Cutters House, School Road, Lowestoft, Suffolk, NR33 INA. Pees aon
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