Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0360, written 7 Dec 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Dec 2017 |
|---|---|
| Reference | 2017-0360 |
| Deceased | Kenneth Cottam |
| Coroner | Anna Crawford |
| Coroner area | Derby and Derbyshire |
| Category | Care Home Health 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Managing Director Coxbench Hall Residential Home Alfreton Road Derby DE21 5BB 1 | CORONER 1am Anna Crawford, Assistant Coroner for the area of Derby and Derbyshire 2 | 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. 3 | INVESTIGATION and INQUEST On 19 April 2016 an inquest was opened into the death of Kenneth Cottam. The inquest concluded on 7 November 2017. The medical cause of death was recorded as: ta.Acute Subdural Haematoma with Mass Effect. The inquest concluded with a narrative conclusion, 4 | CIRCUMSTANCES OF THE DEATH Mr Cottam was an 89 year old gentleman and a resident at Coxbench Hall Residential Home. His mobility was limited and he used a zimmer frame and wheelchair at times, He had not had a fall since 2012 but was nervous about falling. From the morning of 4 April 2016 onwards staff recorded that Mr Cottam appeared confused. On 6 April 2016 he was observed to have a bruise on his right hip and stomach and he reported that on the night of 3/4 April 2016 he had fallen on to his bed. On 8 April 2016 Mr Cottam sustained an unwitnessed fall in his bedroom. He reported that he had lost his balance whilst standing up from his chair. He was checked over by a member of staff who did not observe any injuries and did not have any concerns. On 9 April 2016 a family member became concerned that Mr Cottam’s speech was slurred and staff called an ambulance. Mr Cottam was taken to the Royal Derby Hospital where he was diagnosed with a subdural bleed with mass effect. He was managed conservatively. However, his condition deteriorated and he died at the hospital on 13 April 2016. Having heard evidence, the court was unable to establish whether Mr Cottam had sustained his head injury as a result of the reported fall on 3/4 April 2016 or the subsequent fall on 8 April 2016. The court heard evidence that a falls risk assessment was not carried out in relation to Mr Cottam, either on his arrival at Coxbench Hall Care Home on 1 March 2016, or after he reported having fallen on 3/4 April 2016. The court also heard that no consideration was given to a potential link between the confusion that Mr Cottam had been experiencing since 4 April 2016 and the fall that he reported sustaining on the night of 3/4 April 2016. As a result, the GP, who saw Mr Cottam on 8 April 2016 in relation to his ongoing confusion, was not informed about the reported fall or bruising. CORONER’S CONCERNS Having heard evidence from the management team at Coxbench Hall Care Home, the court was not reassured that there are clear and robust policies and procedures in place in relation to falls prevention and falls management, or that those policies and procedures are widely and consistently understood by staff. The MATTERS OF CONCERN are as follows, — (1) The court was not reassured that there are clear and robust policies and procedures in place in relation to falls risk assessment and management. (2) The court was not reassured that staff had a sufficient understanding of the falls policies and procedures in place to enable them implement them consistently and appropriately. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation has the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date. I, the Coroner, may extend the period on request, 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: 1 2. Care Quality Commission 3. The Chief Coroner | 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. ANNA CRAWFORD 7 DECEMBER 2017
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.
Coxbench Hall Residential Home Alfreton Road, Coxbench, Derby DE21 5BB Telephone: (01332) 880200 Fax: (01332) 881199 E-Mail: office@coxbench-hall.co.uk Web site: www.coxbench-hall.co.uk ee Ms. A. Crawford, Assistant Coroner, Delivered by hand Coroner’s Court, St. Katherine’s House, St. Mary’s Wharf, Mansfield Road, Derby. DE13TQ 30" January 2018 Dear Ms. Crawford, Kenneth Granville Cottam deceased — Reg. 28 Report We are writing in response to the Matters of Concern which are as follows, and to reassure the Coroner’s Court that we, as a matter of course, do all that we can for our Residents in the subject of falling. (1) The Court was not reassured that there are clear and robust policies and procedures in place in relation to falls risk assessment and management. (2) The Court was not reassured that staff had a sufficient understanding of the falls policies and procedures in place to enable them to implement them consistently and appropriately. You have in your possession some documentation that I delivered to your office the day after the Inquest, i.e. on 8"" November 2017, being documents that we had had with us at the Inquest but which were not brought to your attention at the time. That documentation included the items listed on the attached ‘Taking to Inquest re Mr. Cottam — 07/11/20177!. We now enclose the following: Falls Policies”. All staff sign a ‘Policy Checklist’ form once when they join the Company to prove that they have been shown the Policies and where they are kept, and then sign again annually, and they are encouraged to re-read the Policies and Procedures as often as possible. Continued overleaf ... * List of documents taken to Coroner’s Office on 07/11/2017 ? Falls Policy and Accident Reporting Policy Enjoy your retirement years in elegant surroundings with the support of top quality, family style care. er xz Registered No. 1746888 When there is an accident or incident, the staff who is ‘first on the scene’ completes an accident report form. This gets sent to the Office Manager, who checks that the General Manager has seen it — indicated by the General Manager’s signature on the form (obviously if she hasn’t, the form is sent to her). The Office Manager checks whether it is a matter that needs further investigation, or whether the matter has been dealt with and the Resident is all right so that the form can be filed. The General Manager also does this, but also ensures that the fall, if it was a fall, is noted on the Falls Audit form? and all other procedures have been attended to; i.e. the following procedures which are carried out by Carers and Senior Carers: She will check the Daily Care Report entries by the care staff. She will check that a Body Map has been done. Body Mapping Policy attached’, She will check that there is a Falls Diary and Incident Analysis form’ in the Resident’s Support Plan (perhaps this is a first incident and there wasn’t one previously). Staff know that for each fall, the following forms must be completed, so the General Manager will also check that these have been done: Falls Risk Assessment Tool®; Falls Risk Assessment Screening Tool’; Falls Checklist — Environmental Factors’, Following Policy, a ‘Risk Assessment for when there is a high risk of falls’ form? is commenced on the occasion of a second fall. There are two versions of this risk assessment as some Residents prefer that their falls mat is plugged in only at night for example, so the alternative risk assessment is then used. We hope that the above answers the Regulation 28. We should be very grateful if you would please let us know if it does not. su = For and on behalf of Coxbench Hall Ltd. 3 Falls Audit form — [blank example] * Body Mapping Policy ° Falls Diary and Incident Analysis form ° Falls Risk Assessment Tool 7 Falls Risk Assessment Screening Tool * Falls Checklist — Environmental Factors ° Risk Assessment for when there is a high risk of falls x2
See every Prevention of Future Deaths report matching Care Home Health related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.