Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0358, written 13 Sep 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Sep 2016 |
|---|---|
| Reference | 2016-0358 |
| Deceased | Arthur Adley |
| Coroner | Andrew Walker |
| Coroner area | London (North) |
| Category | Hospital Death (Clinical Procedures and medical management) 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.
Her Majesty’s Coroner for the Northern District of Greater London (Harrow, Brent, Barnet, Haringey and Enfield) North London Coroners Court, 29 Wood Street, Barnet EN5 4BE Telephone 0208 447 7680 Fax 0208 447 7689 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Department of Health Richmond House 79 Whitehall London SW1A 2NS 1 CORONER I am Andrew Walker, senior coroner, for the coroner area of Northern District of Greater London 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 9th day of April 2016 I opened an investigation into the death of Arthur Thomas Adley , aged 92 years old. I opened an inquest on the 22nd day of April 2016. The inquest concluded on the 13th September 2016. The conclusion of the inquest was “Consequences of a fall”, the medical case of death was 1a Cardio respiratory failure, 1 (b) blunt force trauma to the head and neck and associated complications. 4 CIRCUMSTANCES OF THE DEATH On the 8th April 2016 at about 7.30 Arthur Thomas Adley, who was a resident at Candle Court Nursing Home, was pushed by another resident and caused to fall striking his face and head on a table as he fell. The resident who had pushed Mr Adley was regularly assessed with regard to his suitability to remain at Candle Court Nursing Home. Steps were taken to protect other residents and the resident who had pushed Mr Adley by ensuring that there were no obstacles in that resident’s way. On this occasion the member of staff looking after Mr Adley in the lounge at the nursing home was aware that the resident who was likely to push other residents was leaving the lounge but had left Mr Adley for a moment. In that moment the resident approached Mr Adley and pushed him over. This incident happened at 7.30 in the morning. Her Majesty’s Coroner for the Northern District of Greater London (Harrow, Brent, Barnet, Haringey and Enfield) Mr Adley was taken to hospital where he died the same day. There were 10 incidents over 3 years where the resident who pushed Mr Adley touched other residents in a way that may have resulted in a fall and on some occasions did result in the resident being pushed and falling causing injury. 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. – That the systems for safeguarding for residents who present a risk to other residents when placed in care homes did not prevent that risk to other residents. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have 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 Thursday 8th December 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;- 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 13th September 2016
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.
Philip Dunne MP Minister of State for Health Department of Health Richmond House 79 Whitehall London SW1A 2NS Andrew Walker . Lo. Tel: 020 7210 4850 Senior Coroner — Northern District of Greater London North London Coroner Court 29 Wood Street Barnet ENS 4BE [hee he Othe Thank you for your report to Secretary of State. | am responding as the Minister with responsibility for quality and regulation policy at the Department of Health. \8 November 2016 I was sorry to read of the very sad circumstances surrounding Mr Adley’s death, please pass my condolences to his family and loved ones. The CQC is the independent regulator of health and adult social care providers in England. I have, therefore, sent your report to the Care Quality Commission (CQC) as the body with oversight in the case. Under the Health and Social Care Act 2008 (the 2008 Act) all providers of regulated activities have to register with CQC and follow a set of fundamental standards of safety and quality below which care should never fall. The fundamental standards describe the basic requirements that providers should always meet, and outline the outcomes that services users should always expect. The CQC inspect the providers against these fundamental standards and their inspections ask every provider are they safe, effective, caring, well led and responsive to people’s needs. One of the fundamental standards relates to safeguarding service users from abuse and improper treatment. This regulation requires providers to establish systems and processes and operate them effectively to prevent abuse of service users and to investigate immediately if the provider becomes aware of any allegation or evidence of abuse. The CQC has published guidance to providers on how to meet the regulations and under ‘Safeguarding service users from abuse and improper treatment’. In regulation 13, the CQC advises that providers must do all that is reasonably practical to mitigate risks. They should follow good practice guidance and must adopt control measures to make sure the risk is as low as is reasonably possible. They should review methods and measures and amend them to address changing practice. The full regulation can be found on the CQC website at http://www.cqc.org.uk/content/regulations-service- providers-and-managers Thank you for bringing the circumstances of Mr Adley’s death to our attention. Hor sone i PHILIP DUNNE
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