Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0279, written 27 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 | 27 Sep 2017 |
|---|---|
| Reference | 2017-0279 |
| Deceased | Pamela Craigie |
| Coroner | Gemma Brannigan |
| Coroner area | West London |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. 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: 1. Advinia Healthcare Limited re: Cloisters Nursing Home, and 2. The London Borough of Hounslow 1 CORONER I am Gemma Brannigan, Assistant Coroner for West London 2 CORONER’S LEGAL POWERS I 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. 3 INVESTIGATION and INQUEST The inquest into the death of Mrs Pamela Craigie was heard with a jury on 14 September 2017. 4 CIRCUMSTANCES OF THE DEATH Mrs Craigie was admitted to Cloister's Nursing Home, owned and managed by Advinia Healthcare Ltd on 21 December 2016. She had dementia and was mobile with the aid of a frame with wheels. She had fallen before, in hospital. The written plan at the Home was for a member of staff to be in the 'communal area' at all time. In the Home, she had a four falls: 1. On 18 January 2017 she fell in her room. An alarm sensor mat was then placed next to her bed. 2. On 31 January 2017 she fell in the lounge. This was witnessed by a staff member. Mrs Craigie had been sitting in a chair, she suddenly stood up, lost her balance and fell, hurting her face. She would not always remember to ask for help when she got up to mobilise, due to her dementia. 3. On 11 February 2017 she had her third fall in the Home. This time it was not witnessed by a member of staff, as staff were taking other residents to and from the dining room. Mrs Craigie had been sitting in a chair in the lounge, she was found on the floor and had hurt her forehead. After this fall, she was referred to the GP for physiotherapy. On 22 February 2017, a physiotherapist advised that Mrs Craigie needed 'constant instruction' to walk with a frame, and that she should have a sensor mat for her chair. The Home telephoned to order a sensor mat on 23 February. 4. On 24 February Mrs Craigie fell again in the lounge, where she had been sitting in a chair. This fall was not witnessed by staff, who were again taking residents to and from the dining room. Mrs Craigie was taken by ambulance to hospital where an acute subdural haematoma was diagnosed. Mrs Craigie remained bed-bound, and was returned to the Home for 1 palliative care. Mrs Craigie died as a result of her head injury on 19 March 2017 at Cloisters Nursing Home, 70 Bath Road, Hounslow, TW3 3EQ. The jury returned the following in relation to the time, place and circumstances of the death: Pamela Craigie was admitted to Cloisters Care Home on 21st December 2016. She was subsequently deprived of her liberty for one year on 28th December 2016. Mrs Craigie died on 19 March 2017 at Cloisters Care Home as a result of a head injury sustained from a fall at the same location on 24 February 2017.Measures outlined in Mrs Craigie’s care-plan completed on her admission were not consistently adhered to. On the day of her fall on 24 February 2017 specifically, Mrs Craigie was not always supervised in the communal area. And their conclusion was: Accidental. The Home had decided that Mrs Craigie did not need 1:1 care (or constant supervision), and she was not assessed or referred for funding for this. Before her death, there would not always be a member of staff in the lounge, especially at meal times. I was reassured to hear evidence from the Home that now: 1. 2. there is always a member of staff in the lounge, even at meal times, and there are sensor mats available to use on chairs. 5 CORONER’S CONCERNS However, I was concerned to hear evidence of the following: In relation to Advinia Healthcare Ltd 1. A resident would only be likely to warrant funding for 1:1 care if they were falling "almost every day, or every week". There is no set number of times they would be required to fall. However, it is not clear from the staff who gave evidence, when a referral for funding for 1:1 care should be made to the local authority, and based on what criteria. The Home should ensure that the criteria for 1:1 care is clear to staff. 2. That it is 'very difficult' to get funding from the local authority for 1:1 care. I am concerned that applications to the local authority for urgent 1:1 care are not being made, because the Home feel that they have been refused before and that a future application will not be successful. The Home should ensure that where the criteria for 1:1 care is met, that a referral for funding is always made. In relation to London Borough of Hounslow 3. If the Home does consider that a resident needs urgent 1:1 care e.g. because of a very high risk of falls, the Home sends a referral form to the London Borough of Hounslow. In their experience it takes two, or two-and a half weeks, for the urgent multi-disciplinary team (MDT) meeting to occur. This seems to be a very long time for an urgent assessment. In relation to Advinia Healthcare Ltd 4. Following the above, in the interim, the Home informs the family that the resident is a high risk of falls, but it is not clear how the high risk is managed effectively until 1:1 care is put in place (or until the MDT meeting). The Home should ensure that steps are taken to ensure the safety of the resident in the interim. I note that the London Borough of Hounslow (LBH) was not an interested person to the inquest. Mention of LBH arose only after the jury had retired to make their determination. 2 6 ACTION SHOULD BE TAKEN I feel that action should be taken in relation to the above. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by. I, 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Person: 1. The family of Mrs Craigie I 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. 9 27 September 2017 3
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.
DVINIA; AN Health Care St Medana Holdings Limited 3° Floor, 314 Regents Park Rd London N3 2)X @® 020 8371 7810 & 020 8343 3845 ~% www.advinia.co.uk Ms Gemma Brannigan West London Coroner’s Court LBHF Gi Assistant Coroner for West London i 25 Bagleys Lane Fulham RECEIVED London ; ; SW6 2QA 10" November 2017 Dear Ms Brannigan Re: Response to the Regulation 28 Prevention of Future Deaths Report in relation to Mrs Pamela Craigie Following the investigation and inquest into the death of Mrs Craigie, the Company has reviewed your report and wishes to respond in the following terms: 1. The Home should ensure that the criteria for 1:1 care is clear to staff. The Company has reviewed its Falls Prevention Policy and has updated its risk assessments in line with that amended Policy. The Policy now clearly states the protocol that staff are to follow should a resident require 1:1 care: Falls Prevention Policy, page 11, section 14 However, if a Resident continues to have frequent falls, defined as 2 or more per month, and all equipment is in place to manage this risk and there has been input from the local falls team and/or G.P, and the Resident still continues to experience a high number of falls, then the Home Manager will liaise with the Commissioners to request a re-assessment of needs. This may result in 1:1 support for that person to manage the risk. In these situations, the Home Manager will liaise with the Operations Manager to request a re-assessment or specific funding. 2. The Home should ensure that where the criteria for 1:1 care is met, that a referral for funding is always made. The revised Falls Prevention Policy was issued to all homes within the Company, including Cloisters, in October 2017 and all Registered Managers will ensure that the policy is followed and will refer residents for 1:1 care when the criteria is met. ADVINIA HEALTH CARE LTD. Regd in England & Wales. Regn. No. 3446822 Registered Office: C/o Gerald Edelman, Edelman House, 1238 High Road, Whetstone, London, N20 OLH DVINIA. W Health Care St Medana Holdings Limited 3 Floor, 314 Regents Park Rd London N3 2JX @ 020 8371 7810 & 020 8343 3845 “® www.advinia.co.uk 3. Point 3 relates to London Borough of Hounslow. 4. The Home should ensure that steps are taken to ensure the safety of the resident in the interim. The Company has outlined, so far as is reasonably practicable steps, to manage the risk whilst waiting for funding in the interim. This is outlined in the Falls Prevention Policy, page 11, section 14 Home Managers should also consider other avenues of support such as (1) requesting family involvement in the supervision of their relative (2) consideration of confinement (3) increased levels of alertness and awareness on the part of all staff (4) updated care plans and in particular, updated mobility risk assessments and (5) the involvement of (external) professionals such as physiotherapists and the falls team to advise on specific measures, until a decision on funding has been made. Where 1:1 support has not been secured due to funding, the Home Manager must consider whether the Resident’s placement at the Home can continue safely. To conclude, the Company has discussed this case in full in order to attempt to minimise the risk of falls. Learning has taken place within the Company. However, it is important to note that although a resident may have 1:1 supervision and or be supervised in a communal setting, the risk of fall occurring may still be high despite those increased supervision levels. Yours sincerely Michelle Macadangdang Operations Manager South Cc: EE Chief Operating Officer — Advinia Health Care Ltd | Quality Manager — Advinia Health Care Ltd HQWSENEEE, Home Manager — Cloisters Nursing Home P| Solicitor — Penninsula ADVINIA HEALTH CARE LTD. Regd in England & Wales. Regn. No. 3446822 Registered Office: C/o Gerald Edelman, Edelman House, 1238 High Road, Whetstone, London, N20 OLH
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