Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0078, written 16 Mar 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Mar 2017 |
|---|---|
| Reference | 2017-0078 |
| Deceased | Terence White |
| Coroner | Simon Fox |
| Coroner area | Gloucestershire |
| 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.
H M Assistant Coroner for Gloucestershire Dr Simon Fox QC REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Grange Care Centre, Leckhampton, Cheltenham, Gloucestershire, GL53 9ER, Clo a] DAC Beachcroft Claims Ltd, 100 Fetter Lane, London EC4A 1BN CORONER | am Dr Simon Fox QC, Assistant Coroner for Gloucestershire. 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. INVESTIGATION and INQUEST On the 5.4.16 1 commenced an investigation into the death of Terence James White. The investigation concluded at the end of the inquest on 14.3.2017. The conclusion of the inquest was natural causes. The medical cause of death was 1a Sepsis and Hypertensive Cardiac Failure 1b Infected Sacral Pressure Sore. CIRCUMSTANCES OF THE DEATH Mr White died in part from infection from a grade 4 sacral pressure sore which developed at The Grange Care Centre between January and March 2016. 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. — The Care Centre records documented the presence of the pressure sore appropriately but there was a very substantial absence of documentation recording measures in place to treat the pressure sore and in particular a very substantial absence of turning charts making it impossible for Senior Staff to know if the condition was being treated properly. 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 4pm on 4" May 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. Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3D) Tel 01452 305661 | Fax 01452 412618 COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons (1) Family — Son in Law, (2) EES - Glos. NHS Trust, Cheltenham General Hospital, Sandford Road, Cheltenham, GL53 7AN (3) Care Quality Commission, CQCinquestsandCoroners1@cqc.org.uk and 151 Buckingham Palace Road, London, SW1W 9SZ | 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. Dated 16 March 2017 Signature Simin Fi so Dr Simon Fox QC Assistant Coroner for Gloucestershire Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3D) Tel 01452 305661 | Fax 01452 412618
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.
Rico Healthcare JET Bondeare House 18 Lodge Road Loudon, NW teF “Yel: 0208 202 22877 Bias 0208 905 3351 E-niail: info@ricohealtheare.co.uk Dr Simon Fox QC Assistant Coroner Gloucestershire Coroner's Court Corinium Avenue Barnwood Gloucestershire GL4 3DJ 21/04/2017 Dear Sir Response to Regulation 28: Report to Prevent Future Deaths - Inquest touching the death of Terrence James White | am writing in response to the Regulation 28: Report to Prevent Future Deaths in order to set out the actions taken in response and additionally proposed to be taken foliowing the death of Mr Terrence James White. The Coroner stated the matters of concern were as follows: “The Care Centre records documented the presence of the pressure sore appropriately but there was a very substantial absence of documentation recording measures in place to treat the pressure sore and tn particular a very substantial absence of turning charts making it impossible for Senior Staff to know if the condition was being treated properly." Having considered the findings of the Coroner we have taken the following actions The Home has made several changes to ensure that record keeping for resident's care plans are more thorough and staff are accountable for the records produced during their shift:- e The daily records that the carers complete such as food and fluid intake, turning/repositioning, general wellbeing and activity charts are now kept in individual folders for each resident easily accessible on each floor. e Every chart contained within the individual folder is then signed off by the nurse responsible for the shift before the evening handover. This sign off is recorded and signed for with any additional notes on the Daily Allocation sheet for each unit. We enclose a copy by way of demonstration. « The Allocation sheets are then checked the following morning by either the Manager or Deputy Manager to ensure that all documents are duly completed and to an appropriate standard, Rivo Lealtheue a Rico Healthcare poe Boudcare House 18 Lodge Road Loudon, NWO ESF ‘Tok: 0208 202 2277 Bax: 0208 905 3. Kanal: inlo@ricolicaltlicare.co.uk In addition to the changes in relation to the documentation we have also introduced further measures to ensure pressure sores are suitably identified: « A "Skin Integrity Board" has been created for each of the units, with clear guidelines and pictures identifying the grades of pressure sores and the potential causes of the same. This ensures that staff are familiar with pressure sores and will be able to identify and report any type of pressure sore to a senior member of staff. « Staff have been undergoing supervision and refresher training in respect of skin integrity with the Home Manager who is a qualified Tissue Viability Link Nurse There have also been changes with regards to archiving documentation:- * Anew Home Administrator was appointed in early May 2016. « He now ensures that all relevant documentation is archived correctly in a neat and orderly manner which can then be retrieved as and when required. * Archiving boxes are now used and marked up accordingly. « Weare currently working through the old archives to put it in order and easily accessible should they need to be accessed. Notwithstanding the improvements to the archiving system, we have been carrying out further searches and have located further records for Mr White. | have attached these records to confirm that although a robust system was not in place at that time, the relevant records were in existence. On behalf of the Company | would like to apologise for the delay in providing these additional records Should the Coroner require additional information in respect of the actions taken or planned please do not hesitate to get in touch with me Yours Sincerely Director For and on behalf of The Grange Care Centre Cheltenham Rico Lealtheare
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