Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0438, written 7 Oct 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Oct 2016 |
|---|---|
| Reference | 2016-0438 |
| Deceased | Norman Beard |
| Coroner | Margaret Jones |
| Coroner area | Stoke on Trent and North Staffordshire |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
for Stoke-on-Trent & North Staffordshire
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
| THIS REPORT IS BEING SENT TO:
1. Mr Matthew Tee
Chief Executive Officer
Care First Homes
17-19 Leek Road
Cheadle
| Stoke-on-Trent
| ST10 1JE
CORONER
14
{am Margaret J Jones, assistant coroner, for Stoke-on-Trent & North Staffordshire.
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:/Avww.legislation.qov.uk/ukpga/2009/25/schedule/5/paragraph/7
http:/Avww.legislation.qov.uk/uksi/2013/1629/part/7/made
INVESTIGATION and INQUEST
On 25" February 2015 | commenced an investigation into the death of Norman Arthur BEARD
aged 87 years. The investigation concluded at the end of the inquest on 27th September 2016.
The conclusion of the inquest was that Mr Beard died from infected pressure sores to which
neglect contributed. The cause of death was given as:-
ta. Sepsis.
1b. Infected pressure sore.
Il. Urinary tract infection.
CIRCUMSTANCES OF THE DEATH
The deceased suffered a fall at his home address on 9th October 2014. He was admitted to the
University Hospital North Staffordshire and transferred to Leek Moorlands hospital on 11th
October 2014 for rehabilitation. He developed small moister lesions on his bottom which were
referred to tissue viability nurses and treated. He was eating and drinking well and his weight
| was stable. He transferred to Daisy Bank Nursing Home Cheadle on 22nd November 2014. The
home's management team were often absent and communication between management and
staff proved difficult. Financial difficulties resulted in staff, equipment, food and other essential
supply shortages. Clear protocols and polices were not in place. The deceased developed
serious pressure sores. No contact was made with tissue viability nurses until 15th December
2014. Advice to upgrade his mattress was not followed. There was confusion with regards to
further referrals to the tissue viability nurses and a second referral was not made until 5th
January 2015. Records were not fully maintained and there were gaps in turning charts. The
deceased was sometimes noted to be non-compliant with his medication and care regime. He
lost over 3 stone in weight during his 7 week stay. There was no referral to district nurses,
dietician or mental health services. The involvement of the general practitioner was minimal.
Blood tests revealed a raised erythrocyte sedimentation rate indicating possible infection but no
treatment was prescribed and there was no further investigation. Tissue viability nurses attended
on him on 7th January 2015. He was found to be in pain. He had infected pressure sores,
contracted limbs and significant weight loss. He was readmitted to Leek Moorland Hospital on
8th January 2015 and found to have extensive multiple pressure sores and dehydration. He was
| transferred to Abbey Court Nursing Home, Buxton Road, Leek on 3rd February 2015 and died
there on 14th February 2015.
Coroner's Chambers, 547 Hartshill Road, Stoke-on-Trent, ST4 6HF
Tel 01782 234777 | Fax 01782 232074
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. —
(1) The home known as Daisy Bank Cheadle has now closed however there are three other
care homes which remain under that same ownership of J and managed by the
same Chief Executive, Mr Tee.
(2) Poor management and absences of management staff was evident during the inquest. The
home manager was not registered and was not medically qualified.
(3) Financial difficulties led to shortage of staff, food and other equipment.
(4) There were no clear policies and procedures in place.
(5) Mr Beard's deteriorating pressure ulcers were not referred to the Tissue Viability Nurses in a
timely fashion and advice, once given, was not followed. Turning charts were not filled in
and an upgraded mattress was not provided.
(6) Mr Beard lost a significant amount of weight. There was no referral to a dietician,
physiotherapist, mental health services or involvement of District Nursing Teams.
(7) The involvement of the GP was minimal and there was no follow up when blood tests
revealed an abnormality.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you or your
organisation has 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
Wednesday 30" November 2016. |, the assistant 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 and to the following Interested Persons:
1. Pp (daughter of the deceased)
2. EERE (daughter of the deceased)
3. ES, BLM Law
4. Cac
5. ie Adult Safeguarding
6. ERR, Staffordshire & Stoke-On-Trent NHS Partnership Trust
7.
HERE Staffordshire Police
(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.
19 | Signature:
tf
Coroner's Chambers, 547 Hartshill Road, Stoke-on-Trent, ST4 6HF
Tel 01782 234777 Fax 01782 232074
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