Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0434, written 6 Dec 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Dec 2016 |
|---|---|
| Reference | 2016-0434 |
| Deceased | Joyce Crompton |
| Coroner | Rachael Griffin |
| Coroner area | Manchester (West) |
| 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.
REG ULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form ts to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Mr Nick Dykes, Chief Executive of CLS Care Services, Nantwich, Cheshire | Lee CORONER'S LEGAL POWERS CORONER I am Rachael Clare Griffin, Assistant Coroner, for the Coroner Area of Manchester West 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. INVESTIGATION and INQUEST | ce On the 28" January 2016 I commenced an investigation into the death of Joy: Crompton, born on the 20" March 1936. The investigation concluded at the end of the Jury Inquest on the 2™ December 2016. The Medical Cause of Death was: Ta Airway Obstruction b Regurgitated food in the mouth and pharynx TI Vascular Dementia underlying cause of Vascular Dementia. The conclusion at the Inquest was Choking on regurgitated food, with the CIRCUMSTANCES OF THE DEATH On the 26" January 2016 Joyce Crompton was found in an unresponsive condition in the bathroom of her room at her place of residence at Belong Village, 55 Mealhouse Lane, Atherton. She had been eating her evening meal prior to this in the dining area. She got up from the table and was later found in her room with food in her mouth and food on the floor beside her. Prior to her death she had been witnessed to have two incidents of choking. One on the 14% September 2015 and one on the 10" December 2015. On the latter occasion the paramedics and out of hours GP had attended. The GP had advised that she should be referred to the Speech and Language Therapy (SALT) Team for assessment_of her swallowing. This was not done. At the time of her death Joyce was the subject of a Deprivation of Liberty Safeguarding Authorisation. 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. During the inquest evidence was heard that: When a resident at Belong Village chokes there should always be a referral to the SALT team to assess their swallowing. A fax is sent by the home to the GP who then will submit a referral to the SALT team. Once the fax has been sent to the home the staff will chase up the referral by telephone. If a referral is done it will be recorded in the GP healthcare visits section of the resident's notes. There is no written policy or procedure in place and staff are given verbal advice on referrals to outside agencies, such as SALT, when they start working at the home. There is no systematic checklist to complete to ensure a referral has been done or to confirm when the referral has been chased. After the witnessed choking incident Mrs Crompton experienced at Belong Village on the 14" September 2015 a referral was not sent to the GP or to SALT. After the witnessed choking incident Mrs Crompton experienced on the 10" December 2015 at Belong Village, a referral was not made to the GP or to SALT. It was recorded in the notes and the home diary that a referral to SALT was to be done, but none of the staff did the referral. The staff who gave evidence at the Inquest all confirmed that they had presumed that it had been done, however there was no record on the GP Healthcare visits sheet that a referral had been done. I have concerns with regard to the following: It is clear that although there is verbal training given on referrals to outside agencies, such as SALT, there is no written guidance that can be easily referred to when incidents arise. There is also no refresher training on the policies. Due to this there may be another occasion in the future when a referral to the SALT team is missed which could result in a future death. I therefore request that a review is undertaken of the policies, procedures and training in place at Belong Village in relation to referrals to the SALT team to avoid future referrals being missed. ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and/or your organisation 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, 31° January 2017. 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: (1) Mrs crompton’s son on behalf of the family (2) Hill Dickinson LLP on behalf of the Speech and Language Therapy team (3) The Care Quality Commission, North Region I am also under a duty to send the Chief Coroner a copy of your response. T have also sent a copy to Wigan Borough Clinical Commissioning Group, Wigan Life Centre, College Avenue, Wigan, WN1 1N3. 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. Dated Signed 24 , i A 6™ December 2016 Rachael C Griffin
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.
RECEIVED Belong
Pepper House
{ 16 DEC 2016 Market Street
ler: Nantwich
i PY b= 5 YF 29 OP YY PF oe a a ay a
f sc tL iC ( Cheshire
CW5 5DQ
a T: 01270 615900
. E: enquiries@belong.org.uk
Your ref: ww beloue oreck
Ms R C Griffin
Assistant Coroner
Manchester West
H M Coroner’s Court
Paderborn House
Howell Croft North
Bolton
BL1 1QY
Dear Ms Griffin
Joyce Crompton - Deceased
| acknowledge receipt of your letter dated 6 December 2016 and the Regulation 28
and 29 report to prevent future deaths.
| acknowledge that the conclusion of the Inquest was choking on regurgitated food
with the underlying cause of Vascular Dementia.
| note the Coroner's matters of concerns and would like to provide you with my
response:
i. No written Guidance regarding referrals to outside agencies such as
SALT
! can confirm that Belong does have a set of Policies and Procedures that provides
clear guidelines for staff about when to refer to other professionals. Our policy
‘Nutrition and Hydration’ provides staff with clear guidelines about when to refer
individuals to the Speech and Language Therapist (SALT). The policy states that:
“advice should always be sought to assist staff with swallowing strategies and
appropriate positioning and to minimise the risk of aspiration or choking for the
person with an unsafe swallow”.
The guidance also references a flow chart in Appendix 1 that provides information
about When to refer to the Speech and Language Therapy team for Dysphagia’.
In addition to this guidance we have the following documentation:
Belong is part of CLS Care Services Limited, a Registered Society under the Co-Operative and Communities ey
fit Societies Act 2014, registered ber 27346R. Registered in England & Wales at Pe; H. a
Benefit Societies Ac! gistered number ‘egistel in Eng ‘ales a per House, Ca y INVESTORS
Y Vv
Market Street, Nantwich, Cheshire CWS 50Q, v
Xf” IN PEOPLE
Marvellous Mealtimes policy - section 15 ‘Swallowing Difficulties’ — ‘Refer for a
swallowing assessment and advice from the Speech and Language Therapist
(SALT).
MUST Assessment for the risk of Malnutrition - ‘A person who has swallowing
problems - notify GP, ask for referral to a speech and language therapist.
Document on care plan’.
Daily Food Intake records - all reference the national descriptors of food type
that has been prescribed.
Life Plan - Food and Drink - a section for ‘These are the difficulties that | have’
to be documented.
Care Practice Guidelines - Food and Drink
| acknowledge that whilst we have the necessary Policies, Procedures,
Guidelines and documentation in place staff have failed to refer to them when
caring for this lady and have failed to seek external advice from healthcare
professionals and to document any changes.
| can confirm that the following actions have taken place:
All Belong Managers and Nurses have been reminded of the importance of
following the Organisation’s policies and procedures and reminded to raise
awareness with their staff teams.
Staff have been requested to reassess all residents’ risk of choking and
ensure follow up referral are made to SALTs with immediate effect.
A meeting is being held on Wednesday, 21 December with all Belong
Registered Managers to review the Policies, Procedures and Guidance and
discuss how we can be more effect in our delivery of safe care.
Staff at Belong Atherton have received update training about Dysphagia and
this will be cascaded throughout the organisation.
The Learning and Development team will review induction procedures and
resources for learning will be evaluated, as will frequency of updates.
All Support Workers have been reminded of the correct procedures to follow
and how to seek advice from outside professionals and when they need to
escalate health concerns. This is incorporated into the care practice training
for all staff, to include staff induction, supervision, life plan review and audit.
| trust that my response will provide you with the reassurance that we have reviewed
and communicated our procedures following the Coroner’s concerns over the death
of Joyce Crompton, and therefore improved the safety of our practice.
Yours sincerely
Nick Dykes
Chief Executive
Belong
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