Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0416, written 23 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 | 23 Nov 2017 |
|---|---|
| Reference | 2017-0416 |
| Deceased | Ronald Jones |
| Coroner | David Horsley |
| Coroner area | Portsmouth and South East Hampshire |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This from is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: , Director Of Property and Housing Services, Portsmouth City Council, Civic Offices, Floor 5 Core 2-3, Portsmouth, Hampshire, PO1 2AY 1 CORONER I am David Clark HORSLEY, Senior Coroner for the area of Portsmouth and South East Hampshire 2 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. 3 INVESTIGATION and INQUEST On 12/05/2017 I commenced an investigation into the death of Ronald Frank JONES aged 88. The investigation concluded at the end of the inquest on 21/11/2017. The conclusion of the inquest was: Mr JONES medical cause of death was 1a Bronchopneumonia, 1b Congestive Cardiac Failure, 1c Cardiac Hypertrophy and Amyloidosis, II Fractured Ribs, Chronic Kidney Disease, Diabetes Mellitus and Frailty of Old Age. My Conclusion was Narrative Conclusion: Ronald Frank JONES died as a result of the processes of natural disease accelerated and significantly contributed to by a fall he sustained in his home on 25 January 2017. 4 CIRCUMSTANCES OF THE DEATH On 25th January 2017 Mr JONES, a resident of sheltered housing at Arthur Dann Court, Portsmouth, fell in his bathroom. He was found by a Night Support Assistant and subsequently moved to his bed by a Night Responder. He was admitted to Hospital the next day where he died on 4th February 2017. 5 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 CONCERNS are as follows: I was told in evidence at Mr JONES inquest that following his fall, he was moved to his bed by personnel who had not undergone first aid training as this had been discontinued by Portsmouth City Council. If persons are moved following a fall, unless this is done correctly, there is a risk that they may be injured or their existing injuries exacerbated, potentially fatally. The Council should consider re-activating this training for all staff involved with residents in the City council's sheltered housing schemes. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe Portsmouth City Council have the power to take such action. Coroner for Portsmouth and South East Hampshire Coroner’s Court, 1 Guildhall Square, Portsmouth, PO1 2GJ Tel: 023 9268 8326 or email: coroners.office@portsmouthcc.gov.uk 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by January 18, 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Mr JONES next of kin and useful or of interest. , Deputy Chief Executive and City Solicitor, Portsmouth City Council who may find it I 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. 9 David Clark HORSLEY Senior Coroner for Portsmouth and South East Hampshire Dated: 23/11/2017 Coroner for Portsmouth and South East Hampshire Coroner’s Court, 1 Guildhall Square, Portsmouth, PO1 2GJ Tel: 023 9268 8326 or email: coroners.office@portsmouthcc.gov.uk
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.
S) Portsmouth Property & Housing CITY COUNCIL . Services Civic Offices - Guildhall Square Floor 5 Core 3 Portsmouth PO1 2AY Telephone: 023 9283 4266 Date: 12th December 2017 Dear Mr Horsley REGULATION 28 REPORT MR R JONES Thank you for your report regarding the investigation into the death of Mr R Jones and the concerns raised regarding training for the sheltered housing staff. | have investigated this matter and have found the following. | have discussed this with P| Deputy Chief Executive and also made the Director of Adult Social Care aware for reasons that will be clear in the response below. | appreciate that there is a level of detail here which may adjust the action you proposed and in light of that would be happy to meet with you and Michael if that is helpful. General points Portsmouth City Council Housing Service Sheltered Housing Staff - roles, responsibilities and training The sheltered housing staff only provide housing related support to help residents maintain independent living in our sheltered schemes. All sheltered housing staff attend a 'responding to accidents and sudden illness' course which covers the typical type of incidents that arise in the schemes. All sheltered housing staff receive ‘handling people’ training which involves both theoretical and practical training. This training takes place for new members of staff and then every member of staff attends refresher training on this topic every 3 years. In addition to this, sheltered housing staff undertake Falls Prevention Awareness training which looks at risks and how these can be minimised. The training is only to support residents that just need support to get up following a fall and does not equip the sheltered housing staff to lift residents that have fallen. We do not expect nor train our sheltered housing staff to lift residents. Sheltered Housing Schemes In our Category 2.5 schemes such as Arthur Dann Court, there is on - site staff presence 24 hours a day, with a Scheme Manager and a team of Support Assistants. Between 22.00 and 7.00, on - site cover is provided by a carer who is employed by a Care Agency. The carer is an employee of a care agency who have been commissioned by Adult Social Care to provide care to clients in the area. The service provided is a sleep - in service, with the carer responding to calls from residents via the in - house alarm system. In the event that a resident has fallen and cannot get themselves up and are in pain, then sheltered housing staff will contact the emergency services to send a paramedic, or in the event of a fall between the hours of 21.00 and 6.00 then they will contact the Night Responder Team for Support. The Night Responder Team is a service provided by Adult Social Care. The team are trained to respond to situations where a resident has fallen and the resident requires support to lift them. They do have first aid training and they operate in pairs. In our category 1 & 2 schemes there isn't a 24 hour staffing presence and out of hours the resident would pull a cord which links to a response centre and they would send the appropriate emergency service to attend if appropriate. The specific Sheltered Housing Scheme and the Incident Arthur Dann Court is a category 2.5 sheltered scheme. The residents have their own flats and as outlined above there is on site housing support provided by PCC housing sheltered housing staff between the hours of 7.00 and 22.00 with a care agency-employed sleep - in carer as the first point of response between the hours of 22.00 and 7.00. The carer is first aid trained. Some residents in Arthur Dann Court and other sheltered housing schemes need help with their personal care and in these circumstances, a care package is arranged by Adult Social Care and this care is delivered by the zoned care agency commissioned by Adult Social Care. The Specific Incident on 25 January 2017 At 22.30, Ronald Jones of [EEE called for help and the sleep - in carer found him in his bathroom hanging onto his frame with his right arm stuck. The carer put a pillow on the floor in case he fell and she managed to free his arm so that he was able to sit on the floor. On finding Mr Jones in this situation, the carer did not attempt to lift Mr Jones and took the correct action by calling the Night Responder Team for support. Two Team Leaders from this team arrived at 23.00 and the report from this team reads: Received call from night warden, on arrival client on floor in bathroom, checked all over bruising to lower right arm, assisted to stand from floor, walked with frame through to bedroom, client very unsteady on his feet, when settled in bed client complained of pain in his back came over hot and sweaty and breathing changed, night warden called paramedics to attend, left client with paramedics and night warden, left property 00:35. Summary In light of these findings it does not seem that additional training in first aid for Portsmouth City Council Housing sheltered housing staff teams is required. The training they have is tailored to their role and responsibilities. The Night Responder Team who did attend to Mr Jones do have the appropriate training to lift Mr Jones and are first aid trained. Please do not hesitate to contact me should you require any future information Yours sincerely Director of Property and Housing Copy: Deputy Chief Executive Director of Adult Social Care
See every Prevention of Future Deaths report matching David Horsley, 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.