Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0278, written 28 Sep 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Sep 2017 |
|---|---|
| Reference | 2017-0278 |
| Deceased | Pauline Hayston |
| Coroner | Timothy Brennand |
| Coroner area | Manchester (West) |
| 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.
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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.
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by staff. A situation, background, assessment and recommendation has been issued
to staff, re-iterating the responsibilities of staff in the operation of the fall mats, and
this has been discussed at safety huddles and handovers. Finally, a training package
is being developed in collaboration with Ramblegard Ltd, along with a competency
assessment tool.
I am informed that Ramblegard Ltd attended the Trust in November to carry out
testing of the mats and no faults were found. I understand that the Trust has
confirmed to you that there have been no other incidents on the wards regarding fall
mats failing to activate.
I hope this information offers clarity and assurance on the operability of the fall mats.
I am aware that you have addressed your Report to Ramblegard Ltd and the Trust,
and hope the further detail they provide is helpful.
Learning lessons from incidents such as these is essential to ensuring the NHS
provides safe, high quality care. It appears that the Trust has taken a range of
measures to assure the operability of the fall mats and improve staff awareness and
competence in their use.
My officials have ascertained that this product does not fall within the regulatory
remit of the Medicines and Healthcare products Regulatory Agency or the Health and
Safety Executive.
My officials have noted that the product information sheet for the Ramblegard Ltd
wireless monitor states that it is CE approved and compliant with Radio and
Telecommunication Terminal Directive (R&TTE, now the Radio Equipment
Directive (RED), June 2017). The product may fall within the regulatory remit of
Ofcom or Trading Standards and I would suggest contacting them if you have further
concerns regarding the product.
Finally, in liaison with the NHS Shared Business Services (SBS), Departmental
officials have established that Ramblegard Ltd products are sold under one of its
Framework agreements that enables NHS organisations to contract with suppliers of
fall prevention products. Ramblegard Ltd products are supplied by one of the six
awarded Framework suppliers.
Only suppliers whose products have passed the quality criteria in the tender can be
appointed under the Framework agreement. Such quality is also warranted by the
supplier to SBS under the terms of the Framework agreement. The Framework gives
NHS organisations the ability to purchase goods from qualifying suppliers, pursuant
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