Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0153, written 8 May 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 May 2017 |
|---|---|
| Reference | 2017-0153 |
| Deceased | David Sheppard |
| Coroner | Louise Hunt |
| Coroner area | Birmingham and Solihull |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT [S BEING SENT TO:
1. Boldmere Court Care Home
2. Care Quality Commission
3. Department of Health
CORONER
Jam Louise Hunt Senior Coroner for Birmingham and Solihull
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 15/08/2016 | commenced an investigation into the death of David Sheppard who died at Good Hope
Hospital on 03/08/16 aged 66. The investigation concluded at the end of an inquest on 5th May 2017.
The conclusion of the Jury at the inquest was
“On 31st July 2016, inadequate action was taken to help the deceased from choking. Failure to give
appropriate medical assistance in an immediate timeframe. A lack of training and communication
between caregivers ultimately resulted in the deceased being rushed to Good Hope Hospital where he
later passed away due to a severe hypoxic brain injury. In conclusion his death was contributed to by
neglect.” :
CIRCUMSTANCES OF THE DEATH
The deceased suffered from vascular dementia and a previous stroke. He became a resident at Boldmere
Court in July 2013. He had challenging behaviour and was cared for on the challenging behavioural unit
however, he was able to verbally communicate his needs. On 31/07/16 he was given a doughnut at 23:22
and went back to his own room. Soon after he was found by a carer outside his room, pointing at his
throat and unable to communicate verbally. The carer took the deceased back into his room, leaving to
find the nurse who was on another floor. During this time another carer checked on the deceased and
raised the emergency alarm at 23:38. Various members of staff attended, including 2 nurses who entered
the room. A nurse checked the deceased's airways which appeared clear, however the deceased still had
breathing difficulties and could not communicate. The first ambulance call was placed at 23:41 stating
the deceased was having difficulty breathing. Staff brought crash mats into the deceased’s room. In this
period all members of staff who initially attended the alarm call, continually left and re-entered the room
until 23:48 when CPR commenced by a carer. Soon after starting CPR a piece of doughnut came out of
the deceased’s mouth. There were points during this time where the deceased was left alone. At 23:49 a
second ambulance cal! was placed, stating the deceased was now in cardiac arrest and not breathing.
The ambulance arrived 6 minutes later. When the paramedics arrived there was no CPR in progress and
no airway assisting the deceased’s breathing. The paramedics noted the deceased had agonal breathing.
They took over care and resuscitated the deceased several times. The deceased was then taken to
hospital where he arrived with a pulse and a Glasgow coma score of three. The deceased was treated in
A&E where food particles were found in the airway. The deceased was resuscitated and taken to ITU
where he was found to have suffered a severe Hypoxic Brain Injury as a result of the cardiac arrest which
was caused by choking on a doughnut. Following this, a decision was made to withdraw treatment and
let nature take its course. The deceased later died at Good Hope Hospital! on the 3rd August 2016.
Following information from the Deceased’s treating clinicians the medical cause of death was
determined to be:
da. HYPOXIC BRAIN INJURY
1b. CARDIAC ARREST
1c. CHOKING
2. VASCULAR DEMENTIA, HYPERTENSION
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. —
4. Communication. There are three areas where communication is a concern:
a. The initial nurse who attended the deceased after the emergency call had poor English and
needed to give evidence at the inquest through an interpreter. The carer who started CPR
had very poor English and also gave evidence through an interpreter. The evidence heard at
the inquest was that the response to this emergency was chaotic. Inability of staff to
communicate with each other contributed to the chaos and poor decision making.
b. Staff failed to pass on an accurate history of what had happened to the deceased resulting
in there being a poor understanding of his initial complaint — namely that the deceased was
pointing to his throat and was unable to communicate. These factors would indicate
choking.
c. The patients on the challenging behavioural unit are extremely vulnerable and many suffer
from dementia and other conditions. Staff being unable to communicate effectively with
these patients may cause harm and confusion,
2. Record keeping. Staff failed to keep an acute and contemporaneous note of the events that
occurred with timings. This made reconstruction of the event extremely difficult.
3. Training. Several of the staff who gave evidence had not received first aid training. They did not
understand the signs of choking displayed by the deceased.
4, Post event investigation. The quality of statements produced by staff immediately after the
event was extremely poor. Subsequently staff had a very poor recollection of what happened
which seriously hampered the inquest. Direction needs to be given to ensure that accurate and
contemporaneous statements are taken after such an incident to ensure events are accurately
recorded to enable the correct lessons to be Jearnt.
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 3 July
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
i have sent a copy of my report to the Chief Coroner and to the following Interested Persons
The _
| have also sent it to Nursing and Midwifery Council 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.
08/05/2017
Signature
Louise Hunt Senior Coroner Birmingham and Solihull
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.
A Philip Dunne MP Minister of State for Health Department of Health Richmond House Our reference: PFD-1085354 * penne SWIA 2NS Your reference: 115279 - DAVID SHEPPARD (LH/AS) Tel: 020 7210 4850 Mrs Louise Hunt HM Senior Coroner Birmingham & Solihull Areas Coroner’s Court 50 Newton Street Birmingham B4 6NE %: Dear Lomise , P sx, Tu ly 2017 Thank you for your letter of 9 May 2017 to the Secretary of State about the death of Mr David Sheppard. I am responding as the Minister with responsibility for workforce and quality regulation at the Department of Health. I was very saddened to read of the circumstances surrounding Mr Sheppard’s death. Please pass my condolences to his family and loved ones. I have noted very carefully the conclusion of the inquest and the areas of concern you have detailed. Clearly, the failure to take adequate action in response to Mr Sheppard’s fatal situation was unacceptable. I can appreciate how distressing these circumstances must be for Mr Sheppard’s family. All registered providers of health and social care in England are required to provide safe, effective, compassionate and high quality care and to meet the fundamental standards of quality and safety as set out in Regulations (Health and Social Care Act 2008 (Regulated activities) Regulations 2014) www. legislation.gov.uk/uksi/2014/2936/contents/made. It is the responsibility of Boldmere Court Care Home as the registered provider to ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced persons deployed and appropriately trained as necessary to enable them to carry out their duties. It is the responsibility of the Care Quality Commission (CQC), as the independent regulator of health and adult social care in England, to monitor, inspect and regulate services to make sure they meet the fundamental standards of quality and safety. You have therefore taken the correct action in addressing your Report to the CQC and Boldmere Court Care Home who will respond on the specific matters of concern you have raised. I understand the provider has taken a number of measures to address concerns including, but not limited to, the provision of training with first aid, CPR and choking prioritised in the induction process, as well as documentation training sessions and the introduction of an incident reporting questionnaire. I am aware that the CQC conducted an inspection of Boldmere Court Care Home in January 2017, resulting in a rating of ‘Good’ overall with no breaches of regulation identified. At this inspection the CQC reviewed the provider’s progress on the actions it had taken in light of this incident. ! am assured that as part of its inspection programme, CQC will continue to monitor that service user’s needs are being met through verbal and non-verbal communication skills at Boldmere Court. The CQC will also monitor that the provider continues to meet the required standards around ensuring staff receive appropriate support, training, professional development, supervision and appraisal as necessary to enable them to carry out the duties they are employed to perform (Regulation 18); and that systems and processes are in place to ensure compliance with the requirements around maintaining accurate, complete and contemporaneous records for people receiving care (Regulation 17). You mention in your Report that two nurses were involved in the incident. As you may be aware, nurses must register with the Nursing and Midwifery Council (NMC), and meet professional standards to work in the UK, and be fit for practise. This includes sufficient knowledge of the English language to be able to perform their roles. For registered nurses, we expect the NMC’s registration processes and associated checks to be appropriate, robust, fit for purpose, effective and to verify that the applicant is who they claim to be and that they are appropriately qualified, competent and fit to practise and have the ability to speak English to the required standard, The NMC has three different registration processes ~ UK, Europe and the rest of the world. The NMC requires all overseas applicants, defined as those who trained outside the European Economic Area (EEA), to complete the academic version of the International English Language Testing System (IELTS) achieving level 7.0 across all four aspects of listening, reading, writing and speaking. a Department of Health The NMC also requires those European trained applicants who are unable to provide sufficient evidence of English language skills - such as having trained or worked in an English-speaking country — to complete an English Language Assessment to the required standard. Where there is concern that a nurse may not meet the professional standards required in the UK, the NMC has a duty to investigate and, where necessary, take action to safeguard the health and well-being of the public. Fitness to Practise allegations can relate to concerns over a nurse’s ability to communicate effectively in English, in addition to matters such as clinical competence. I note your report has been shared with the NMC. I should clarify that the Department does not get involved with or comment on individual fitness to practise cases. There is no requirement for language testing non-regulated workers, such as care staff. However, social care employers are responsible for ensuring that their staff are trained and competent for the tasks they are recruited to do. This includes the ability to communicate effectively. Communication is covered within the Care Certificate. However, there is no explicit reference to being proficient in the English language. The Care Certificate is an identified set of standards that health and social care workers adhere to in their daily working life. Designed with the non-regulated workforce in mind, the Care Certificate provides confidence that these workers have the same introductory skills, knowledge and behaviours to provide compassionate, safe and high quality care and support. Further information on the Care Certificate can be obtained from the Health Education England website https://hee.nhs.uk/carecertificate. I should point out that the Care Certificate also covers awareness of mental health, dementia and learning disabilities so that staff supporting people with challenging behaviours have a basic awareness of their needs. At Boldmere Court Care Home, I am advised that this is supplemented with mandatory training and hands-on training with staff and patients. LT hope this reply is helpful in setting out the national requirements and regulations around these areas of concern. Thank you for bringing the circumstances of Mr Sheppard’s death to our attention. (MO PHILIP DUNNE
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