Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0411, written 22 Nov 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Nov 2017 |
|---|---|
| Reference | 2017-0411 |
| Deceased | Kathleen Devine |
| Coroner | Timothy Brennand |
| Coroner area | Manchester (West) |
| 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) NOTE: This form is to be used after an inquest. 4 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Manager and Owners, “Bloomcare”, Arden Court Nursing Home, 76 Half Edge Lane, Eccles, Salford. CORONER I am Timothy W Brennand, HM Assistant Coroner for the Coroner Area of Manchester West. 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. INVESTIGATION AND INQUEST On the 19" day of June 2017 I commenced an investigation into the death of Kathleen Joan Devine, aged 94. The investigation concluded at the end of the inquest on the 8" November 2017. The medical cause of death was determined to be:- Ta Acute Left Ventricular Failure Ib Hypertensive Heart Disease Il Surgery for Fractured Neck of Right Femur caused by a Fall Advanced Dementia There was a narrative conclusion that Kathleen Joan Devine died as a consequence of a combination of naturally occurring disease and injuries sustained in an accidental fall exacerbated by recognised complications of necessary surgical intervention and post-operative recovery. CIRCUMSTANCES OF THE DEATH The deceased had a history of advanced dementia, osteoporosis, osteoarthritis and previous falls by reason of her aged related compromised mobility and was a resident at the Arden Court Nursing Home, 76 Half Edge Lane, Eccles. On the 8" June 2017 the deceased suffered an un-witnessed fall in her room whilst attempting to mobilise unsupervised in circumstances that remain unclear. A safety mat and sensor in the room had been unplugged and moved but it cannot be established that this had any bearing on the outcome. The deceased experienced increasing pain through the day and was subsequently transferred to the Salford Royal Hospital, Eccles Old Road, Salford where she was diagnosed with a fracture to her right femur. On the 9" June 2017, the deceased underwent a corrective right hemiarthroplasty conducted without event. Post 1 operatively, the deceased's condition deteriorated by reason of the effects of surgery and her frailties and despite active treatment on the 10° June 2017 she became unresponsive and died at 4.44am that day. 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: The deceased sustained serious injuries as a result of an un-witnessed accidental fall in her room whilst attempting an unsupervised and unassisted mobilisation. The deceased had been correctly assessed as presenting as a high falls risk and required the deployment of a falls mat and sensor in her room at the Nursing Home. The mat and sensor had been unplugged and moved from the correct placement whilst the deceased was still in the room by herself. The last note of recorded care, intervention or observation was made at 6.30am on the 8" June 2017 stating that the deceased was asleep. The accident occurred at about 8.30am. By reference to the routine, after waking, the deceased would be placed on a chair near to her commode in the room. By inference, the fall took place as the deceased attempted to mobilise onto her commode. The evidence did not establish whether the deceased has mobilised from her bed or from her chair. The member of staff on duty at the time of the fall was an agency nurse who stated that there was no specific information on any handover sheet or care plan to the extent that she did not know who needed a mat or otherwise. Accordingly, the evidence established the following concerns:- The failure of staff to record observations between 6.30am and 8.30am; The removal and unplugging of a falls mat and sensor in the room of a resident with high risk falls who was awake, unsupervised and unobserved; The quality and extent of handover instructions to agency staff; ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe that 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 17 January 2018. 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:- 1. (Son), 2. Salford Adult Safeguarding Board, Salford City Council, 2" Floor, Civic Centre, Swinton M27 5DA Tam 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. Timothy W Brennand, 22" November 2017 HM Assistant Coroner
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.
RECEIVED 05 DEC 27 Arden Court 76 Half Edge Lane Eccles M30 9BA T: 0161 240 3273 Timothy W Brennand H M Coroner’s Court Paderborn House Howell Croft North Bolton BL1 1QY 28" November 2017 Dear Mr Timothy Brennand, Further to the Regulation 28 regarding the death of Kathleen Joan Devine, | have enclosed comprehensive information on how further deaths can be prevented in the future, these are the changes that have been contrived: At Arden Court every resident who has a crash mat and/or sensor mat now has a precise care plan purely for maintaining safety with regards to the crash mat and sensor mat. Within the care plan documentation, this meticulously gives guidance to staff to ensure that the crash mat and sensor mat are in the correct place, certify that all equipment is used precisely, in good working order and the fundamental aim of this care plan is to reduce the risk of falls and promote safety. Therefore, all staff must comply to this care plan to know exactly how to safely care for a resident with a crash mat and/or sensor mat (Appendix 1: Care Plan). Anew system that has now been enforced, is that every resident who has a crash mat and/or sensor mat has this included on the daily handover sheet in bold capital letters next to the resident’s name. The daily handover sheet is a typed document that provides a brief overview of each resident. Therefore, by having this on the daily handover sheet will ensure that any new staff or agency staff are vigilant to which residents depend upon a crash mat and/or sensor mat (Appendix 2: Most updated handover — anonymised). Another new process that is now applied by the staff, is an additional column on the daily mattress check sheet. On a daily basis the staff check that the air flow mattresses are on the correct settings in relation to their weight. The staff document this on the mattress check list which each resident has in their rooms, therefore, the staff are now checking daily that, if needed, the resident has a crash mat and/or sensor mat in place and the staff have to test that the equipment is working correctly and document this. Therefore, this firstly prompts the staff to ensure that the equipment is in their bedroom and secondly, ensures that the staff test and inspect the equipment, to ensure that it is working correctly (Appendix 3: Mattress, Bedrails and Sensor mat check). Additionally, the in house moving and handling training, now includes the importance of not unplugging sensor mats or moving crash mats, this is aimed at all staff, especially staff members such as domestics. The Arden Court 76 Half Edge Lane Eccles M30 9BA T: 0161 240 3273 moving and handling training also highlights the seriousness of ensuring that equipment is in the correct place when the resident is sleeping in bed and stress the dangers of not being compliant with this. « Changes have also been made to the accident forms, as Kathleen did not receive regular observations after the fall, whereas the new accident forms will ensure regular checks and observations will be made. Therefore, factures or any other complications would be addressed prompted and ensure that the correct treatment is provided rapidly (Appendix 4: Accident Form). e At Arden Court, we have dramatically reduced the levels of agency staff that are used, therefore, we now have regular staff who are aware of the equipment that needs to be in place for each of the residents. Although, if an agency staff member is needed to be used, then they receive a robust handover and clear guidelines of the needs of the residents. e There was no documentation from the times between 06.30-08.30, at Arden Court we now have hourly observation charts for residents who require more frequent checks, such as someone mobile like Kathleen Devine and these are now actively used (Appendix 5: Hourly check form). These are the changes that have been implemented at Arden Court, | fee! that we have learnt immensely from the death of Kathleen Devine and I hope that these changes demonstrate how dedicated we are to prevent events such as this occurring in the future and we also hope that these changes provide closure for the family of Kathleen Devine. Please do not hesitate to let me know if you require any further information. Yours faithfully, Katrina Hay Home Manger — Arden Court
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