Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0232, written 22 Jun 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Jun 2016 |
|---|---|
| Reference | 2016-0232 |
| Deceased | Malcolm Bennett |
| Coroner | John Pollard |
| 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: Borough Care Ltd., 9, Acorn Business Park, Stockport SK4 1AS 1 CORONER ! am John Pollard, senior coroner, for the coroner area of South Manchester 2 | 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 3 | INVESTIGATION and INQUEST On 21" December 2015 | commenced an investigation into the death of Malcolm Bennett dob 20" January 1931. The investigation concluded on the 13" June 2016 and the conclusion was one of Open Conclusion. The medical cause of death was 1a Head Injury. 4 | CIRCUMSTANCES OF THE DEATH The deceased was resident in a Care establishment and whilst there he sustained a number of injuries due to falls and he also became involved in a number of fracas with other residents again sustaining injury. During the late hours of the 15" December 2015 he was allegedly assaulted by a female resident, he was injured but was not taken to hospital until the early hours of the following day. Later that same day, he died at Stepping Hill Hospital as a result of a head injury. There was insufficient evidence to show whether the head injury which led to his death emanated from the alleged assault or from one or more of the falls to which he was prone. 5 | CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concem. 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. — In the care Plan for this person, it clearly indicated that in the event of any significant injury he should be taken as expeditiously as possible to the Emergency Dept. of the hospital. Clearly this was not done, in that the staff left him knowing that he had apparently been hit by someone and he might well be injured, and they did not call for an ambulance for another three hours. In the light of his cause of death, this delay might have been contributory. 6 | ACTION SHOULD BE TAKEN In my opinion action shouid be taken to prevent future deaths and / 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 17 August 2016. |, the coroner, may extend the period. Your response must coniain 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 or of the deceased). | have also sent it to CQC 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,s6nd a copy of this report to any person who he believes may find it useful ” Ypu may make representations to me, the coroner, at the time of your response, abgft the release or the publication of your response by the Chief Coroner. 22.6.16 John Pollard, HM Senior 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.
Our Ref: Borough (ore Your Ref: Po a Mr JS Pollard Head Office: Senior Coroner 9 Acorn Business Park - HM Coroner Manchester South ene ~ Stockport - Coroner's Court Telephone: 0141 475 0140 1 Mount Tabor Street y \ Fax: 0161 475 0164 Stockport \ Web: www.boroughcate.org.uk. SK1 3AG 15" August 2016 Dear Sir Re: Malcolm Bennett (Deceased) — Regulation 28 Report Please find below details of the action Borough Care has taken, or will be taking and the timetable in which actions will be taken, in response to the matters of concern stated within your Regulation 28 Report dated the 22" June 2016. 1 All Home Managers in each of Borough Care’s care homes were instructed to update the risk management plans (which form part of a care plan) for all residents who have been prescribed Warfarin or any other anti-coagulant, with an instruction to ring 999 without delay in the event that a resident has, or is suspected of, having had a fall, accident or injury. Registered Managers at all care homes have been asked to confirm that risk management plans for residents prescribed with such medication have now been updated. 2 The Home Manager at Silverdale met with the senior team to brief them of the matters of concern, and in addition key individuals have received a formal ‘note of concern’ regarding their failure to follow the care plan for Mr Bennett. All care staff at the care home have been reminded of the importance of such matters through the staff supervision process. In addition to the above action, Borough Care has also broadly reflected on the incident to identify if there are any other ways in which its best practice of caring for people prescribed anti-coagulants can be enhanced generally and has identified the following actions: 2.1 Each resident who has been prescribed with an anti-coagulant now has an anti- coagulant warning placed on their care plan and MAR sheet to highlight the fact that the resident is prescribed such medication. 2.2 Information about residents who are prescribed anti-coagulant medication is discussed at staff handovers and team meetings, including reference to the care plan. 2.3 General medication training for staff administering medication has been reviewed to include anticoagulant use and First Aid training has also been revised to include same. 2.4 Borough Care's ‘Falls Prevention and Reporting of Accidents’ policy and procedure will be reviewed and updated by the end of September 2016. Py Kathryn Former Compony Secretary 4 N INVESTORS Silver Borough Care Umited is an Industrial and Provident Society Ny Vid l N PEOPLE eestor pact Business Park, Heston Lane — Stockport SK4 LAS. Regstered number 27788R 2.5 Borough Care's medication audit procedure will be reviewed and revised by the end of September 2016. ! would be grateful if you could acknowledge receipt. Yours sincerely Kathryn Farmer CEO & Co.Secretary
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