Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0281, written 6 Oct 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Oct 2017 |
|---|---|
| Reference | 2017-0281 |
| Deceased | Geoffrey Spencer |
| Coroner | Chris Morris |
| 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 THIS REPORT IS BEING SENT TO: (Vatron / Registered Manager, The Lakes Care Centre, Lakes Road, Dukinfield, Tameside, SK16 4TX CORONER tam Chris Morris, Area Coroner for Manchester South. 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. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST Following the opening of an investigation on 31% May 2017, on 6" June 2017, Andrew Bridgeman, Assistant Coroner for Manchester South, opened an inquest into the death of Geoffrey Spencer who died on 28" May 2017 aged 90 at Tameside General Hospital, Ashton-under-Lyne. The investigation concluded at the end of the inquest which | heard on 5" October 2017. The conclusion of the inquest was that Mr Spencer died from a respiratory arrest secondary to aspiration pneumonia. Whilst multiple serious medical problems placed Mr Spencer at risk of aspiration pneumonia, his death was contributed to by injuries sustained in an unwitnessed fall at his care home. At the end of the inquest, | recorded a narrative conclusion to this effect. CIRCUMASTANCES OF THE DEATH Mr Spencer first became a resident at The Lakes Care Centre in 2015 as a result of the progression of vascular dementia. Although initially Mr Spencer was relatively mobile, in November of that year he had a stroke which diminished his mobility and impaired his ability to swallow safely. On occasion, Mr Spencer became agitated, and input was sought from the Mental Health team and the General Practitioner to try and mitigate this. On 24" May 2017, Mr Spencer was particularly agitated, having had a restless night. At around lunchtime, he was thought to be seated in the lounge area of the Coniston Unit at The Lakes Care Centre, which at all times was meant to be under supervision of an attendant member of staff. At around the time some residents were being helped to the dining room for lunch, Mr Spencer was observed to be on the floor, some distance away from his chair. The evidence at inquest did not disclose how Mr Spencer had come to be on the floor, and particularly whether or not this had occurred whilst the lounge was unintended. Later that day, Mr Spencer was noted to be in pain. An ambulance was called, and Mr Spencer was taken to Tameside General Hospital where a fractured neck of femur was diagnosed. Although Mr Spencer was initially placed on the trauma operating list on 25" May 2017, he was not considered fit for surgery. Mr Spencer developed symptoms of respiratory problems later that day, and treatment for aspiration pneumonia was commenced on 26" May 2017. Very sadly, Mr Spencer’s condition deteriorated further, and he died in hospital on 28" May 2017. 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. Notwithstanding the serious injury sustained by Mr Spencer, and the residual possibility that this was sustained in circumstances where the lounge area was unattended by a member of staff, it is a matter of concern that no formal investigation has been undertaken in relation to this incident by The Lakes. Whilst evidence emerged in the course of the inquest of improvements to the Care Centre's Falls Policy and more formal reporting and analysis of falls at The Lakes, it is a matter of concern that the absence of a formal investigation has reduced the potential for learning to be derived from this incident with a view to improving the safety of other residents. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation 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 1 December 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: 1) a Daughter of the Deceased); 2) (Son of the Deceased). | have also sent it to the Care Quality Commission 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. 6" October 2017 Signature Chris Morris HM 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.
29 NOV 2017 Ac os he ahes Care Centre Chris Morris HM Area Coroner Coroners Court 1 Mount Tabor Street. Stockport, SK1 3AG 28% November 2017 Dear Mr. Morris, This is my response to the Section 28 report raised by you following the inquest of the late Mr. Geoffrey Spencer. You raised concern during the course of the inquest that no formal investigation had been undertaken in relation to this incident, by The Lakes. I responded at the time by informing you that we had recently redeveloped our falls policy, post falls assessment and carried outa monthly analysis of all falls at The Lakes. The concerns you raised led me to reflect on our current practice and review what we could do better. This started with a complete investigation into what had actually happened on the day of the incident; e Timeline of events e Staff and designation on duty? e Who was doing what and where? Once I had done this, it was evident that all of the above were relevant factors in the incident. | will do my best to try and explain this to you; It was lunch time period, the unit is a 25 bedded Dementia Care unit, at that time the occupancy level was 23 residents (2 empty bedrooms), of those 23 residents, 2 residents stayed in their own rooms, which left 21 residents in the communal lounge area. All staff were on duty, our staffing levels are 4 care staff plus 1 activities coordinator throughout the day and 3 staff at night, as this is not a Nursing unit, there are no Nurses employed. The residents of this unit suffer varying degrees of Dementia, not challenging behaviour to the extent of requiring a nursing unit, but certainly disorientation which can lead to agitation and CONFUSION... Blackeliffe Ltd., The Lakes, off Boyds Walk, Dukinfield, Cheshire SK16 4T™X Cus nts avacivties Telepbone: 0161-330 2444 + Fax: 0161-339 0087 Website: unwwdakescare.couk + E-mail info@lakescare.co.uk oe Tass Directors: J. Meredith, B Meredith, L. Meredith R.N.H.A, suet lunch time, 2 members of staff support residents into the dining room, whilst 1 member of staff remains in the lounge area, and 1 staff member stays in the dining room to monitor incoming residents. Because of the very nature of the condition, this process can in itself become quite hectic as mobile residents will start to walk towards the dining room then turn around and go in the opposite direction, with staff trying to manage the safety and maintain a calm atmosphere at all times. In these conditions it is quite feesable that a resident could slip onto the floor from a chair, without being seen by care staff present, as they may be looking and dealing with other residents in the room. By standing back and looking at this, it was clear to me that changes need to be made to optimise and make best use of the resources we have by changing work patterns. In this current climate it is not viable to increase staffing levels whilst the true cost of care is not being acknowledged, therefore I need to look at better ways of working to reduce risk and increase safety. This is what we have done; *See attached; Corrective Action Plan* Yours Sincerely Registered Manager
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