Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0248, written 14 Jul 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Jul 2016 |
|---|---|
| Reference | 2016-0248 |
| Deceased | Harold Goulding |
| Coroner | Nadia Persaud |
| Coroner area | East London |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. FI Nursing Director, Alexander Court Care Centre, 320 Rainham Road South, Dagenham, RM10 7UU CORONER | am Nadia Persaud, Senior Coroner for the Eastern Area of Greater London 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. http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On the 13" November 2015 | opened an investigation into the death of Mr Harold Goulding. The investigation concluded at the end of the Inquest on the 13" July 2016. The conclusion of the Inquest was a narrative conclusion. Mr Harold Goulding suffered 2 falls in his care home on the 5" and 6" November 2015. He was admitted to hospital on the 6" November 2015 where end stage heart failure and an acute on chronic subdural haematoma were diagnosed. On the 1 0" November 2015 he suffered a seizure from which he did not recover. The most likely cause of the fatal seizure was the trauma of the falls and consequent head injury. CIRCUMSTANCES OF THE DEATH Mr Goulding suffered a fall at the Alexander Court Care Centre in the early hours of the 5" November 2015. He was seen by a GP on 5 November 2015 who checked him for fractures. The GP was not aware that Mr Goulding was on warfarin therapy and there was no record of any assessment for a head injury. The GP had not received reports from the anti-coagulation clinic and he did not check the Care Home’s medication administration record. Mr Goulding suffered a second fall on the 6'" November 2015. He was taken to hospital following the second fall. The main clinical concerns at this time were of shortness of breath, swollen neck and swollen arms/legs. The initial impression upon attendance to hospital was of end stage heart failure. A CT scan carried out on the 7" November 2015 confirmed an acute on chronic subdural haematoma. Mr Goulding remained in hospital and was stable until the 8" November 2015 when it was noted that he was suffering from swallowing difficulties. His family also noted an increase in his level of confusion at this time. On the morning of the 10" November 2015 he suffered from a seizure. Despite anti-epileptic medication and management of his airway, he suffered a cardiac arrest. Life was pronounced extinct at 09:46 on the 10"" November 2015. At the Inquest the cause of death was found to be 1a cardiac arrest 1b seizure 1c fall, head injury and subdural haematoma (on warfarin therapy). 2 congestive cardiac failure; type 2 diabetes and hypercholesterolemia. CORONER’S CONCERNS The MATTERS OF CONCERN are as follows. — 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: 1. The evidence revealed a breakdown of communication between the anti- coagulation clinic, the General Practitioner and the Care Home. The Care Home had registered Mr Goulding with a new General Practitioner but did not notify the anti-coagulation clinic of the details of the new General Practitioner. The community pharmacist therefore continued to provide reports to the old GP. 2. The General Practitioner provided the lead in relation to the administration of medication at the care home. The General Practitioner did not however consider the Medication Administration Record held by the home. The staff providing evidence from the care home agreed that it would reduce risk in the future, if a system is in place to ensure that the General Practitioner attending for new resident reviews, considers and approves the medication set out within the Medication Administration Record. This would not only provide assurance to the Care Home staff in relation to medication that they are administering, but would also ensure that GPs are fully aware of the medication that residents are currently receiving. It was further agreed that in order to reduce future risk, the Care Home staff should take the lead in ensuring that any other health agencies providing care to new residents are informed when the home registers new residents with a new General Practitioner, so that information can be correctly shared. ACTION SHOULD BE TAKEN In my opinion action should 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 9"" September 2016. |, 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 9 the following interested a (daughter of the ee ea forwarding a copy of the report to the Care Quality Commission and to (Director of Public Health) 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. [DATE] /4.7. 1G [SIGNED BY CORONER] IZ
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.
DH Cc AR EH O ME YWrorcHarp www.orchardcarehomes.com Ref: SW/MO/Z/COMP/AC/HG 7 September 2016 Private & Confidential Ms Nadia Persuad Senior Coroner Eastern Area of Greater London Queens Road Walthamstow London E17 8QP Dear Mrs Persuad RE: Alexander Court - The Late Mr Harold Goulding The late Mr Harold Goulding was an 86 year old man admitted to Alexander Court Care Centre from Queens Hospital on the 28" October 2015 with the following Medical History: Heart Failure, Atrial Fibrillation, Stroke, left eye closed, Difficulty in breathing, Prostate Cancer, Type 2 Diabetes, Postural Hypotension and Pacemaker in situ. On 2"4 November 2015 Mr Goulding’s International Normalized Ratio was checked at Alexander Court Care Centre by [EM from Barking & Dagenham PCT Anticoagulant Clinic (Contact No: 02025946188. }. Mr Goulding suffered a fall in the early hours of 5'" November 2015. He was seen by the GP, I from Porters Avenue Surgery for post fall checks and initial assessment as a new resident and advised the Home to continue with the care as Mr Goulding was stable. Mr Goulding was observed throughout the day and there were no significant changes in his condition. The GP was not aware that the late Mr Goulding was on Warfarin therapy and there was no record of assessments for a head injury. On the 6" November 2015 at around 15.01hrs, Mr Goulding suffered a second fall. He was found lying on the crash mattress at the side of his bed in his room. An ambulance was called immediately as Mr Goulding was complaining of breathlessness and swelling was noted around his neck. When the ambulance arrived they took Mr Goulding to the hospital for further treatment. Whilst in hospital, a CT Scan was carried out on 7 November 2016. The scan confirmed an acute on chronic subdural haematoma. On the morning of 10‘ November 2016, Mr Goulding suffered a seizure, followed by a cardiac arrest and passed away in the care of the NHS. The Home Manager, Deputy Manager and Clinical Lead have held meetings with all the Nurses employed by Alexander Court. The purpose of this meeting was to discuss the incident with the late Mr Goulding and lessons learnt to prevent similar occurrences. Daily meetings have been put into place with the Nursing staff to ensure that communication is paramount for the daily care of the residents and working with outside Professionals. A protocol document has been created to work alongside the policy of Working with Professionals, to enable better working communications with the Home staff and outside professionals. The Hamlet, Hornbeam Park, Harrogate HG2 8RE Tel: 01423 859859 Fax: 01423 859860 We www.orchardcarehomes.com INVESTOR INPROPLE OrchardCareHomes.com (Holdings) Ltd Registered in England no.6061481 ,Tri-Care Ltd Registered in England no.2235823, OrchardCareHomes.com Ltd Registered in England no.5245993, OrchardCareHomes.com (2) Ltd Registered in England no.6177993,OrchardCareHomes.com (3) Ltd Registered in England no.6883079, OrchardCareHomes.com (4) Ltd, Registered in England no.6881971, OrchardCareHomes.com (5) Ltd Registered in England no.6882622, OrchardCareHomes.com (6) Ltd Registered in England no.6881997, OrchardCareHomes.com (7) Ltd, Registered in England no.08370121, Cherry Health Care Ltd Registered in England no. 04216820, Loxley Healthcare Ltd Registered in England no. 04484936 Yio RCHARD" Cc AR EH OM 5 www.orchardcarehomes.com When the GP visits the Home to attend to the resident's needs, the Nurse on duty will accompany the GP on his rounds and go through the medication administration charts and care plans to ensure all information is shared where necessary. A handover document for use with new resident's details has been created to ensure relevant information is shared with the new GP where required. These protocols that have been put into place, will be followed up by the Home Manager regularly. Yours sincerely Director of Nursing/Nominated Individual q Z£ — ae Ee Nx NS EK The Hamlet, Hornbeam Park, Harrogate HG2 8RE Tel: 01423 859859 Fax:01423 859860 www.orchardcarehomes.com ‘ INVESTOR IN PEOPLE OrchardCareHomes.com (Holdings) Ltd Registered in England no.6061481,Tri-Care Ltd Registered in England no.2235823, OrchardCareHomes.com Ltd Registered in England no.5245993, OrchardCareHomes.com (2) Ltd Registered in England no.6177993,OrchardCareHomes.com (3) Ltd Registered in England no.6883079, OrchardCareHomes.com (4) Ltd, Registered in England no.6881971, OrchardCareHomes.com (5) Ltd Registered in England no.6882622, OrchardCareHomes.com (6) Ltd Registered in England no.6881997, OrchardCareHomes.com (7) Ltd, Registered in England no.08370121, Cherry Health Care Ltd Registered in England no, 04216820, Loxley Healthcare Ltd Registered in England no. 04484936
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