Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0247, written 24 Aug 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Aug 2017 |
|---|---|
| Reference | 2017-0247 |
| Deceased | Joseph Tarnowski |
| Coroner | Chris Morris |
| Coroner area | Manchester South |
| Category | Care Home Health related deaths |
| Organisation named | North West Ambulance Service NHS Trust |
| 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 10: EE Registered Manager, Hillbrook Grange Residential Care Home, Ack Lane East, Bramhall, Cheshire SK7 2BY CORONER | am Chris Morris, Area 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 http://www .legistation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 hitp:/Avwww legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 25th April 2017, Alison Mutch OBE, Senior Coroner for Manchester South, opened an inquest into the death of Joseph Tarnowski who was aged 96 when he died at Stepping Hill Hospital, Stockport on 10th April 2017. The investigation concluded at the end of the inquest which | heard on 4th August 2017. The conclusion of the inquest was that Mr Tarnowski died as a consequence of injuries sustained in a fall at Hillbrook Grange Residential Care home. At the end of the inquest, © | recorded a conclusion of Accident. ; The medical cause of death was 1a) Bronchopneumonia and acute heart failure 1b) (mmobility 1c) Fall, fractured humerus | 4 | CIRCUMSTANCES OF THE DEATH Mr Tarnowski essentially enjoyed good health in his younger days. As years progressed, he developed some serious and debilitating health problems including deteriorating eyesight with wet macular degeneration. He also experienced a number of falls whilst living in his own home and as such, family members encouraged him to move to a residential care setting. Following an initial period living at a home in Bolton, Mr Tarnowski moved to Hillbrook Grange in April 2016. Mr Tarnowski settled into the home well, and essentially appeared to be in good health, although he did develop a number of chest infections. Mr Tarnowski walked independently with the help of a walking aid, and remained wholly independent in respect of most activities of daily living. At all material times, Mr Tarnowski retained capacity to make decisions about the support and assistance he wished to accept or refuse at any given time. On 7th April 2017, Mr Tarnowski fell whilst getting changed in his bedroom. He was unable to get himself up, and called out to staff who came to assist him. Mr Tarnowski was taken to Stepping Hill Hospital, Stockport, by ambulance where a displaced fracture of the neck of the left humerus was diagnosed. Mr Tarnowski was treated conservatively for this injury and admitted to hospital. On 9th April, Mr Tarnowski's condition deteriorated dramatically, and he sadly died the following day. 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. — In evidence at the inquest, it was confirmed that Mr Tarnoswki summoned assistance by shouting out to staff rather than by using his call-bell. it became apparent during the course of the hearing that Mr Tarnowski may not have been aware that his call-bell was wireless, and as such could be moved around his room. Additionally, the evidence revealed that even had Mr Tarnowski been aware that his call- bell was portable, he may not have been able to move it due to his reliance on a mobility aid. At the time of the inquest, consideration had not been given to introducing call bells which are worn by residents of the fashion that are apparently in use in some other similar residential care setting. 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 19"" October 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; ) i sister of the deceased; 2) HEE (Parner, Weightmans LLP, Solicitors to North West Ambulance Service NHS Foundation Trust) | have also sent it to the Care Quality Commission who may find it useful or of interest. | 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. 24/08/2017 Christopher Morris. Area Coroner Manchester South
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.
Ack Lane East, Bramhall, Cheshire SK7 2BY ILLBROOK GRANGE eae www hillbrookgrange.co uk Making our home your home info@hillbrookgrange co.uk September 14, 2017. frcvin ANLED Dear Mr. Morris RE: Joseph TARNOWSKI In light of your recent Regulation 28 Report, you identified that we at Hillbrook Grange Residential Care Home could do more in respect of preventing future deaths. You gave rise to concern that there is a potential risk that future deaths will occur unless immediate action is taken. | | Iam happy to say that from this verdict and report we have taken prompt and responsive action by way of providing residents with call bells that are to be worn around their necks. This was immediately actioned following the registered manager’s participation into the inquest. Consequently, the board of directors approved this recommendation and purchased the call bells without delay and the system was implemented within the week. Ours service users are now fully equipped with their mobile call bells and we hope that we have dramatically reduced the risk of serious impediments that result from a resident who may fall. We are greatly appreciative of the recommendations you have provided to us in your report. I believe this has made the environment for the residents at Hillbrook Grange a safe place. We the managers, board of directors and all the staff feel confident in consistently working hard to continuously make our home the best it can possibly be. hope the improvements we have undertaken succeeds to the entireness you required for the recommendations to Hillbrook Grange Residential Care Home. Thank you. Kind regards Jed Ch eee Home Administrator Hillbrook Grange Residential Care Home; registered in England & Wales (no.07125607) Registered charity no. 1146488
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