Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0363, written 11 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 | 11 Dec 2017 |
|---|---|
| Reference | 2017-0363 |
| Deceased | Irene Baker |
| Coroner | Simon Fox |
| Coroner area | Avon |
| 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 (1)
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NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Rosewood Lodge Nursing Home
9 Uphill Road North
Weston-super-Mare
BS23 4NE —
1 | CORONER
lam Dr. S. Fox, Assistant Coroner, for the area of Avon.
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
on17" May 2017 an investigation was commenced into the death of Irene Winifred
BAKER, Aged 84. The investigation concluded at the end of the inquest on a"
December 2017
The medical cause of death was:
la Acute on chronic post-operative cardiac failure
lb Coronary arterial atherosclerosis
{| Recent fractured neck of femur, repaired surgically
Healed myocardial infraction
Cirrhosis of liver, diabetes mellitus
The conclusion of the inquest was Natural causes ’
4 | CIRCUMSTANCES OF THE DEATH
Mrs. Baker died following an operation on a fractured hip which the evidence suggested
-| occurred at Rosewood Lodge Nursing Home. However the Nursing Home had no record
of it. The fracture was recorded under section 2 of the cause of death.
5 | CORONER'S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In |
my opinion there js a risk that future deaths will occur unless action is taken. Inthe
circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. —
1. No revision of the mobility care plan in response to monthly reviews
documenting.a deterioration in mobility in November and December 2016;
2. No monthly mobility reviews were undertaken in January and February 2017;
3. A failure to contact the GP-or call an ambulance in response to a documented
inability to weight-bear 12" - 23" April 2017
ACTION SHOULD BE TAKEN
in my opinion action should be taken to prevent future deaths and | believe you 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 6" February 2018. |, 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 -— the family.
| am also under a duty to send the Chief Coroner a copy of your response.
The Chief Cororier 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.
11° December 2017. Dr. S. Fox fs
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.
ROSEWOOD LODGE
{Registered Reiirement Home)
9 UPHILL ROAD NORTH,
WESTON-SUPER-MARE, |
SOMERSET, BS23 4NE. Telephone 01934 644266 |
4" February 2018
REGULATION 28: | REPORT TO PREVENT FUTURE DEATHS (1)
FAO: Coroner; Dr $ Fox
. Dear Sir,
Jn response to your.concerns raised at an inquest held on 11" December 2017, I respond
as follows:
e I, a 2: employed from 8" May 2017 as Registered Manager and |
have made improvements to Roséwood Lodge highlighted following the ; |
incident which led to the inquest.
° The management team structuie now consists of myself, Registered Manager,
Deputy Manager and Head of Care. ,
e Care plans were completely overhauled and re-written by a his
was evidenced at our North Somerset Council inspection on 14" September
2017) . ,
© In March 2017 we were inspected by North Somerset Council and rated as
Amber, however following improvements implemented throughout the home, on
14" September 2017 we were rated as Green. . . |
® Care plans are reviewed on a monthly basis or before if there are any changes,
risk assessments ate updated accordingly and. support from medical
professionals is raised immediately to ensure we are able to meet their needs at
all times.
® Staff have received further training, and job descriptions outlining their ’
responsibilities during a shift and the expectation of their duties to the residents.
© Head of Care, Deputy Manager and appointed Shift Leader will cover every
shift to ensure continuity of care and high standards are maintained.
e Families are informed immediately when a GP, Occupational Therapist or any
other medical professional has been contacted and they are updated with an
outcome. :
e From 31* January 2018, we have implemented a new computerised care plan
software system, ‘Person Centred Software’ which allows care staff to update
SCOSA LIMITED T/A ROSEWOOD LODGE RETIREMENT HOME.
REGISTERED ADDRESS: - “HAZEL SUAW’, 34 DOWNS WAY, TADWORTH SURREY. RF20 SDZ
TEL/FAX 01737 279667 .
REGISTRATION NO, 4319250
more efficiently, flagging any incidents, accidents, mobility changes etc,
ensuring that the care plans are up-to-date at all times as it is a live system. The
system also allows reports to be printed off immediatey ie: falls, mobility,
nutrition etc to give a better overall indication of any decline in the residents
needs.
Consent has been received from residents and families for Rosewood Lodge to
have CCTV installed in the communal areas to monitor their safety.
Each resident who is high risk of falls or unsteady on their feet has a sensor mat
in their rooms connected to their call bells to highlight the staff should they have
a fall ensuring staff are able to contact the relevant medical support ie: GP,
Ambulance etc,
Ongoing support is received from the Compliance Manager who visits on a
monthly basis as well as the owner.
‘Rosewood Lodge is continuing to make changes to ensure the safety and
wellbeing of the residents is maintained at all times. .
Should you require any further information then please do not hesitate to contact
Yours faithfully
Registered Manager
(OOD LODGE RETIREMENT HOME,
4 DOWNS WAY, TADWORTH SURREY. 8120 5D7,
ABAX 01737 279867
REGISTRATION NO, 4319250
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