Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0027, written 13 Feb 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Feb 2017 |
|---|---|
| Reference | 2017-0027 |
| Deceased | Roger Tombs |
| Coroner | Emma Brown |
| Coroner area | Birmingham and Solihull |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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
THIS REPORT IS BEING SENT TO: Sunrise Senior Living, Solihull Falls Team, Care Quality Commission
CORONER
| am Emma Brown Area Coroner for Birmingham and Solihull
CORONER’S LEGAL POWERS
1 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
On 25/05/2016 | commenced an investigation into the death of Roger Harold Tombs. The investigation
concluded at the end of an inquest on 9th February 2017. The conclusion of the inquest was:
“Mr Tombs died as a result of an accidental fall. His needs had not been adequately re-assessed following
a deterioration in his condition, which contributed to his death.”
In addition the jury made findings on the central issues of the case which were;
1. Was there any error or omission in the level of care provided to Mr Tombs that caused or contributed
‘| to his death? YES
2.Was there any error or omission in the sensor mat system that caused or contributed? NO.
CIRCUMSTANCES OF THE DEATH
On the 4th May 2016 at 03:30, Roger Harold Tombs died at Queen Elizabeth Hospital, after admission
following a fall at Sunrise Care Home in Knowle on the 3 May 2016. Roger was subject to a Deprivation
of Liberty Safeguarding Order, due to his learning disabilities. He was at high risk of falls and had had an
increase in falls leading up to his death.
Following a post mortem, the medical cause of death was determined to be:
1a BRONCHOPNEUMONIA
1b SEVERE TRAUMATIC BRAIN INJURY
2 DEMENTIA (DIFFUSE LEWY BODY TYPE)
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. {n the circumstances it is my statutory
duty to report to you.
The MATTERS OF CONCERN are as follows. —
1. The evidence was that fall sensor mats had been placed either side of Mr. Tombs’ bed on top of
crash mats. At the time of his fall on the 3° May 2016 the sensor mats did not sound an alert
2. The instructions for use of the sensor mats state they should be placed on a hard floor.
3. The investigating police officer from the public protection unit gave evidence that she was
concerned that the crash mats below the sensor mats would reduce the effectiveness of the
sensor mats and this could possibly be the reason the mat didn’t sound (there were other
possible explanations).
4, The evidence was that Sunrise of Knowle is still placing sensor mats on top of crash mats.
5. No expert opinion has been sought on this practice but the evidence of the investigating police
officer was that the managing director of the local distributors of the mats told her this was an
unsafe practice in his view.
6. [tis my opinion that there is a risk that the effectiveness of the sensor mats is being reduced by
placing them on crash mats and if this is the case they may not sound when vulnerable residents
are mobilising exposing them to a risk of falls, injury and potentially death.
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 by
Monday 10" April 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
| have sent a copy of my report to the Chief Coroner and to the following Interested Persons: the family
of Mr. Tombs and West Midlands Police.
1am 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.
13/02/2017
‘Area Coroner Birmingham and Solihull
2 responses 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.
Emma Brown Area Coroner Birmingham & Solihull Areas 50 Newton Street Birmingham B4 6NE 28 February 2017 Dear Ms Brown Roger Harold Tombs (Deceased) I refer to the Regulation 28 Report to Prevent Future Deaths arising out of the Inquest into Roger Tombs dated 13 February 2017 (“PFD Report”) addressed to Sunrise Senior Living (“SSL”). As you are aware SSL is one of the providers registered with the Care Quality Commission in respect of Sunrise of Knowle (“Home”). SSL became registered with the CQC in October 2016 and manages the Home on behalf of Sunrise Operations of Knowle Limited (“SOK”), the other registered provider. SSL was also managing the Home at the time of Roger Tombs’ death on behalf of SOK. It is expected that SSL will be leaving the Home and will be deregistered by CQC on 1 March 2017, with another provider coming in to manage the Home and who will be registered with CQC. SOK remains registered with the CQC. With the imminent departure of my Client from the Home, I would be grateful if you were able to provide guidance on how you would like my Client to respond to the PFD Report. My Client has written to CQC and Solihull MBC Falls Team inviting them to engage in a dialogue on the matters raised in the PFD Report to help SSL inform its Response (copies of the letters are attached). My Client will be able to inform you of the steps it took immediately following the Inquest to address the matters of concern raised by you in respect of the placing of sensor mats on top of crash mats at the Home, but it will not be in a position to describe any measures that may be implemented at the Home post 1 March 2017. My Client would welcome your views on the above and I look forward to hearing from you. Yours sincerely Director, Solicitor
Emma Brown Area Coroner Birmingham & Solihull Areas 50 Newton Street Birmingham B4 6NE By Email only: c/o paul.hodson@birmingham.gov.uk 20 April 2017 Dear Ms Brown Roger Harold Tombs (Deceased) I refer to the Regulation 28 Report to Prevent Future Deaths arising out of the Inquest into Roger Tombs dated 13 February 2017 (“PFD Report”) addressed to Solihull Falls Team (SFD). Firstly, I wish to thank you for the extended time period to respond to this report. The Falls Team was not directly involved in, or present, at the inquest and therefore did not have the opportunity to represent themselves or explain any actions taken in respect of falls prevention training that was provided to the Sunrise Care Home. All conversations related to the case were with the police officer, Sarah Vaughan, and were conducted via telephone following the conclusion of the inquest. Nursing staff working within the Falls Team were contacted by Ms Vaughan to discuss the advice given by the team to Sunrise Care Home in relation to the correct use of sensor mats. The Nurse Lead informed Ms Vaughan that neither she nor any other member of the team had been directly involved with the Mr Tombs’ care, and that the advice that had been provided to Sunrise was standard guidance on the appropriate use of crash mats and sensors. It was confirmed to Ms Vaughan that the standard guidance and training would not have advocated the use of the sensor mats being place on top of crash mats. It can be only be assumed that Sunrise Care Home have misinterpreted the advice provided by the Fall Team which is supplemented by the recommendation that each resident would also need a holistic risk assessment to ensure measures could be put in place to meet each individual’s need. As we are concerned to hear that Sunrise Care Home are still using the sensor mats incorrectly, and as a direct result of the issuing of the PFD Report, I have reviewed practice within the team in relation to the issue of advice and training of this nature and find that it is both consistent and accurate. Furthermore, to support the dissemination of this across the care home sector, a guidance document has been developed outlining good practice in the use of sensor mats and is enclosed for your reference. This was sent on 4 April 2017 to Theresa Scragg - Acting Strategic Commissioner for Older People, Solihull Metropolitan Borough Council (SMBC), for circulation throughout all care homes in the borough. It is my understanding that Ms Scragg intends to add to this guidance and supplement this with further information related to assistive technology available through SMBC but I have not yet seen this additional material. Please do not hesitate to contact me if you require further information Yours sincerely Sam Foster Chief Nurse
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