Ronald Brewer

IN THE GLOUCESTER CORONER’S COURT
IN THE MATTER OF AN INQUEST TOUCHING THE DEATH OF
RONALD BREWER
__________________________________________
Written response of , Director of Nursing,
Barchester Healthcare ltd to the Regulation 28 report
to prevent future deaths issued on 19th October 2017 by
HM Senior Coroner for Gloucestershire, Ms Katy Skerrett
__________________________________________
1. My name is , I am Director of Nursing at Barchester Healthcare, I have
been in post for the last 3 years, but employed by Barchester since 2002. In my role I
am responsible for the strategic development of a clinical framework for healthcare
workers to practice within.
2. These submissions are made on behalf of Barchester Healthcare Limited
(“Barchester”) in relation to the Regulation 28 report to prevent future deaths issued
on 19th October 2017 issued by the Learned Coroner pursuant to Sch 5 Para 7(1) of
the Coroners and Justice Act 2009.
3. Upon receipt of the Coroner’s report I undertook a review of policies, procedures
and practise with a focus upon the concern identified by the Learned Coroner,
specifically, “The administration of medications including in particular the
documentation of and dispensation of palliative medications.”
4. Following my review I can confirm that the following actions have been taken;
a. A Deputy Manager has been appointed at Badgeworth Court with a
background in palliative care and she has been given the responsibility to
support training and practice in end of life care in the home. Also to continue
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after training has been completed to supervise and embed new practices into
every day work and continue and develop the relationships and involvement
of the local palliative care team in the home.
b. The staff at Badgeworth Court have undertaken an assessment of their
competencies and practices in relation to management of medicines and they
have attended further training on this topic and in relation to record keeping.
c. Training has been made available through the Boots pharmacy e‐learning
modules in end of life care. Our registered nurse staff have been required to
complete this training.
d. The General Manager at Badgeworth has arranged for ongoing training over
the next 3 months, the training is to cover;
i. End of Life Care Planning
ii. Anticipatory care needs
iii. Communication
iv. Clinical decision making in medication
v. Medication Management
e. The end of life and management of medication policies have been re‐visited
with staff and we have reiterated the importance of multi‐professional
working in end of life care.
f. Greater emphasis has been placed on anticipatory end of life care during
weekly local GP visits. The home conducts a round of all residents where the
GP and staff can address relevant issues. Although the decision to prescribe
end of life medication is the responsibility of the medical practitioner, it is
best practice to discuss such care using a multi‐disciplinary team approach
involving the local palliative team for advice and guidance.
g. In our review it was noted that during Mr Brewer’s end of life care, a decision
was made to administer Midazolam at a dose at the highest end of the
prescribed dose range. Our finding was that the decision was appropriate
and was made by an experienced nurse having considering the individual
factors specific to Mr Brewer including his height, weight and level of
agitation. Nevertheless, it was identified that more could be done to support
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this type of decision making. The management of medicines and end of life
policies have been reviewed and updated to provide guidance to the nursing
staff on points to consider when administering medication where a range of
dosage has been prescribed, in particular analgesia and controlled
medication in end of life care considering the resident individually in relation
to the initial dose of controlled medications and the tolerance levels which
may lead to naïve residents becoming toxic very quickly.
h. We considered a recording error made when Mr Brewer’s discharge notes
were transcribed on admission. Two staff members failed to correctly
transcribe Rivaroxaban from the hospital chart to the care home MAR chart.
Following investigation the staff members conceded that, during
transcription they had failed to consult the discharge summary and had solely
referred to the hospital MAR. Clinical supervision was given to the two staff
members on the relevant home policy regarding transcription. Both staff
members no longer work in the home.
i. Whilst investigating the drug administration notes and checking remaining
stocks of Zomorph it was noted that a recording error had taken place during
the first administration of the drug at Badgeworth Court. The dose had been
recorded on the hospital MAR chart instead of the newly created home MAR
chart. The error created two distinct risks;
i. Firstly, the record gave the erroneous impression that a tablet of
Zomorph was missing. It was only when the hospital MAR chart and
the controlled drug book was checked that it was discovered that the
shortfall was a recording error,
ii. Secondly, the error created the possibility that a staff member
reading the Barchester MAR chart could have concluded that Mr
Brewer had missed a dose of Zomorph. This could have conceivably
resulted, in a second dose being administered.
The incident was raised at staff supervisions with staff and was focussed
upon as a learning point during staff training and assessment.
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j. Policies and procedures have been updated centrally to reflect good practice
in medicine management and End of life care.
k. The facts of this case, anonymised, will now form the basis of a case study
which forms part of a learning resource for staff during induction and
workshops.
5. Barchester Health Limited is committed to a process of ongoing review to ensure the
highest standards for its service users. Our review of this case has allowed us to
reflect, remediate and improve our service.
Director of Nursing
Barchester Healthcare Ltd
12th December 2017
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