Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0017, written 30 Jan 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Jan 2017 |
|---|---|
| Reference | 2017-0017 |
| Deceased | Frederick Chisnall |
| Coroner | Janet Napier |
| Coroner area | Cheshire |
| 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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. St Helens Clinical Commissioning Group 2. Halton Clinical Commissioning Group 1 | CORONER lam Janet Elizabeth Napier, assistant coroner, for the coroner area of Cheshire 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 7 April 2016 an investigation was commenced into the death of Frederick Chisnall aged 79 of Forshaw Unit, St Mary's Nursing Home, Penny Lane, Warrington. The investigation concluded at the end of the inquest on 19 December 2016. The conclusion of the inquest was that the deceased died due to a myocardial infarction. 4 | CIRCUMSTANCES OF THE DEATH The deceased was subject to a Deprivation of Liberty Order at the time and was being given one to one nursing care, which | was told was commissioned by yourselves, from the two Agencies “Reflex” and “Challenge Recruitment". | believe an Adult Safeguarding investigation was carried out following the death and was not finalised by the date of the inquest. 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. During the inquest concerns were raised about the actions of the Agency staff regarding producing proper documentation, and being aware of how to monitor changes in clinical condition and obtaining medical or nursing help urgently when appropriate. Although in this case this did not cause any serious sequelae, | wonder if you could assess the adequacy of the training given to the staff you commission, to ensure this does not happen in the future. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and 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, namely by 26 March 2017. |, 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 and to the following Interested Persons namely the family of the deceased and the Care Quality Commission. | 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 senda 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: 30 January 2017 Sines:
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.
St Helens Clinical Commissioning Group St Helens Chamber Salisbury Street Off Chalon Way St Helens WA10 1FY 30"" March 2017 Dr J E Napier Assistant Coroner West Annexe Town Hall Sankey Street Warrington WA1 1UH Dear Dr Napier Re: Frederick Chisnall (Deceased) Further to your response letter to Professor Sarah O’Brien, dated 07/02/17, | can provide the following update in relation to the safeguarding investigation and assurance actions taken to mitigate any future risks: Safeguarding Investigation The safeguarding investigation was led by Warrington Local Authority as St Marys where Mr Chisnall resided was within the borough of Warrington this is in line with national guidance and procedures. St Helens Local Authority Safeguarding Unit was apprised of the investigation and the outcomes. The safeguarding case was closed on 23/01/17. There we no actions identified for St Helens through the safeguarding investigation. The safeguarding investigation was partially substantiated it was concluded that there was no evidence of neglect and that Mr Chisnall's death was not caused by a failure of those employed to deliver his care. However concerns did exist in relation to staff record keeping in respect of the agency staff and responsiveness to the changes in clinical condition of Mr Chisnall in respect of a nurse employed by St Mary's. and NS) St Helens Council Chamber Working in partnership with Action Taken as part of the Safeguarding investigation: e Challenge Recruitment- no action taken as no findings e Reflex Agency- further training provided to the staff by the agency * St Mary’s Nursing home- disciplinary action was taken in respect of the nurse by St Mary's. St Mary’s Nursing Home gave assurance that they would no longer use Reflex Agency for non-registered staff. The Team Manager for St Helens Contracts and Quality Monitoring service also liaised directly with the agencies involved for assurance of actions taken following the conclusion of the safeguarding investigation. Since the incident, St Mary's CQC inspection determined that they were good overall. They had quality audits in place and Warrington Borough Council's care quality monitoring team had found no issues with the service. All nurses complete audits of records on a monthly basis which is further quality assured by the home manager. Assurance Further to the above | would like to offer assurance that robust contractual and quality monitoring processes are in place in respect of all placements funded by St Helens CCG and St Helens Local Authority. All service users will be assessed to determine the level of need and the type of placement required and wherever possible this will be provided within borough. Before admission a placement vetting process is undertaken which for out of borough placements will include liaison with the host authority. The service user will receive an annual review and there is a contractual expectation that the residential/ nursing home will review care needs on an on-going basis and advise if there is any significant change in the needs of an individual. In addition for out of borough placements the Local Authority Quality Monitoring Team will undertake regular desk top reviews where they will speak directly with the host authority, the care/nursing home, the service user or representative and check any CQC reports. In respect of the use of agency staff the agency contract is with the care/nursing home. There is a clear expectation that agency staff will be provided with the relevant training, and supervision from the agency and that they work to the care/nursing homes policies and procedures as part of its CQC registration. | hope this answers your additional queries, Yours sincerely Working in partnership with St. lens StHelens Counci! Chamber Chief Nurse a «i: Nurse — NHS Halton CCG and StHelens StHelens Council Chamber Working in partnership with
See every Prevention of Future Deaths report matching Care Home Health related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.