Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0138, written 26 Apr 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Apr 2017 |
|---|---|
| Reference | 2017-0138 |
| Deceased | John Davies |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive Stockport NHS Foundation Trust CORONER tam Alison Mutch, coroner, for the coroner area of South Manchester 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 26" October 2016 | commenced an investigation into the death of John Davies. The investigation concluded on the 6" April 2017 and the conclusion was a narrative one of died of natural causes exacerbated by an infected pressure sore. The medical cause of death was 1a Lewy Body Dementia;ib Parkinson’s Disease; and 2 Infected Sacral Pressure Sore CIRCUMSTANCES OF THE DEATH John Anthony Davies had Lewy body dementia and Parkinson's disease. He was a resident at Cawood House Lapwing Lane, Stockport. His care needs were complex. He was identified as requiring a move from a residential care setting to a nursing home setting. Care was provided by the District Nursing Team and the GP. On the 7th September 2016 he was found to have an infected pressure sare. He was admitted to hospital. His prognosis was poor. On the 6th October 2016 he was moved to the Meadows for palliative care. He deteriorated and died on the 23rd October 2016 at the Meadows. 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. — There was no process in place for risk assessment plans to be completed when a resident's needs changed from care to nursing needs and a bed was awaited. The District Nursing Team were unaware of the change in status and there was no system in place to involve them in discussions. Patient records completed by the District Nursing Team lacked detail and were not completed in the required timescales. There was no continuity of care provided by the District Nursing Team. There was little evidence of communication and information sharing between the care home and the District Nursing Team The Care Home notes were lacking in detail A suitable nursing home placement could not be identified once it had been agreed that the Care Home was no longer the best place to meet the needs of Mr Davies Advice was not sought by the District Nurses when they had difficulties examining Mr Davies 9. The correct procedure was not followed on previous occasions when a trigger | point was reached in relation to pressure relieving strategies. | 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 21* June 2017. 1, 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 nanely son of the deceased, who may find it useful or of interest. lam 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. Alison Mutch HM Senior Coroner 26" April 2017
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.
Stockport NHS) NHS Foundation Trust Our ref. 1922/John Anthony Davies Your ref. 5652/HC Oak House Stepping Hill Hospital Coroner's Court Be ie 1 Mount Tabor Street po! Stockport eos SK1 3AG 4 Telephone: 0161 483 1010 Uc. Fax: 0161 487 3341 Direct line: E-mail: 16" June 2017 Dear Ms Mutch, Re: John Anthony Davies (Deceased) Thank you for your letter, of 26" April 2017, concerning the inquest of the above named patient. As always, | am grateful to you for highlighting your concems on the Regulation 28 ‘Report to prevent future deaths’ and for providing me with an opportunity to respond. Your concerms are as follows: There was no process in place for risk assessment plans to be completed when a resident's needs changed from care to nursing needs and a bed was awaited. A multi-agency risk assessment has been developed this will support residential home managers to provide safe and effective care for patients have been assessed as needing twenty four hour nursing care and are waiting to be transferred to a nursing home. This risk assessment is to be launched at the Stockport Care Home Managers’ meeting in June 2017 and due to be implemented in July 2017. The District Nursing Team were unaware of the change in status and there was no system in place to involve them in discussions. The Stockport District Nursing (DN) service, like many other District Nursing services, recognises the challenges associated with delivering care to patients in a residential home when the patient's care needs change from residential care status to Continuing Health Care (CHC) or Funded Nursing Care status. The DN team who visited this patient within the residential home were unaware that the patient's status had changed; the CHC / Funded Nursing Care team had not informed the DN staff, nor had the staff within the residential home. The DN Pathway Lead met with a representative of the Stockport Clinical Commissioning Group CHC team to discuss how communication could be improved between the CHC team and DN teams. As a result of the discussion it has been agreed that the CHC staff will, as a matter of course, use the Contact Access and Triage service (CATs) to invite DN staff to patient CHC/Funded Nursing Care meetings. Patient records complete by the District Nursing Team lacked detail and were not completed in the required timescale. The Trusts accepts that the patient's District Nursing notes did lack detail especially araund the deterioration of the patient's physical and mental health and were not completed in the required timescale, This has been addressed with the team and a reflective session has been facilitated regarding the patient's nursing care. An audit of the team's patients’ notes has been carried out by the DN Clinical Lead and improvements have been noted. The Patient Records audit is being repeated to ensure that the improvements have been sustained. Your Health. Our Priority. There was no continuity of care provided by the District Nursing Team The Named Nurse for the each care home will undertake all visits to the residents within their allocated home; however, when not on duty, the Named Nurse will hand over any relevant information to whichever nurse is assigned to visit. The information in the handover will include details regarding risks, non-compliance, patient issues and care planning. The visiting nurse will then hand over to the Named Nurse when he/she is back on duty. This process will be overseen by the Caseload holder. There was little evidence of communication and information sharing between the care home and the District Nursing Team A new Named Nurse has been appointed to the residential home involved in this case. This nurse will ensure communication and documentation is improved and this will be overseen by the DN Caseload Holder (Band 6 Nurse). The Named Nurse now attends monthly meetings at the residential home with the manager and the staff to ensure all aspects of patients' care are discussed and communicated to the DN team. The home manager will also invite Adult Social Care staff, District Nursing staff, GP and home care staff to the meeting for ongoing discussion of the patients’ care. The key information from these meetings will be recorded and shared at the ON ‘Time Team’ meeting. Implementing the above will improve continuity of care to the residents of the home and also improve working relationships with the staff within the home. The Care Home notes were lacking in detail The Care Home notes are not the responsibility of the Trust, and we respectfully request that this concer is forwarded to the Care Home. A sultable nursing home placement could not be identified once it had been agreed that the Care Home was no longer the best place to meet the needs of Mr Davies Locating and assessing Nursing Home placements is not the responsiblity of the District Nursing Team, and we respectfully request that this concern is forwarded to the Stockport Clinical Commissioning Group's Funded Nursing Care team to be addressed. Advice was not sought by the District Nurses when they had difficulties examining Mr Davies District Nursing staff are experiencing Increasing challenges when nursing patients with mental health problems or conditions associated with mental health or behavioural issues. The ON team accept that advice should have been sought from other professionals when the patient's behaviour affected the ability to provide DN care. Good practice would have been to speak to mental health practitioners for advice or to have undertaken a Joint visit in order to ensure best care was given to the patient. Stockport Together, a major transformation programme across the health and social care partners in Stockport, has been instrumental in enhancing multi-professional and multi-agency working, bringing together health professionals from a variety of backgrounds, social care and the third sector to benefit patient care. A Community Psychiatric Nurse now attends Neighbourhood Triage meetings on a monthly basis alongside the Psychiatric Consultant and these meetings provide an open forum for discussion about individual patients with challenging situations, such as in Mr Davies’ case. HE (Consuttant Psychiatric Doctor for Older People) is also planning educational events with the District Nursing staff from July 2017 in order to help and support the DN staff in the management of patients with Dementia. District Nursing staff have also been advised through discussion at Caseload Holders meetings, Locality meetings and Local Leadership and Triage meetings that if they are involved in the care of any residential care home patients who display signs of declining physical or mental health they must obtain the contact numbers for the patients next of kin so that they can make contact and discuss possible strategies to improve compliance with care. The correct procedure was not followed on previous occasions when a trigger point was reached in relation to pressure relieving strategies The Trust has a Prevention and Management of Pressure Ulceration Guideline (2015). All members of staff in the District Nursing team have been reminded of the requirement to adhere to this guidance and new staff have been booked on to the mandatory pressure ulcer training which includes how to identify trigger points and provide pressure relieving strategies.
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