Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0439, written 11 Jul 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 Jul 2017 |
|---|---|
| Reference | 2017-0439 |
| Deceased | Doreen Willis |
| Coroner | Ian Arrow |
| Coroner area | Plymouth, Torbay and South Devon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Torbay and South Devon NHS Foundation Trust |
| 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.
for Plymouth Torbay and South Devon REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Care Quality Commission,Citygate, Gallowgate Newcastle upon Tyne, NEI 4PA CORONER !am_ lan Michael Arrow, the Senior Coroner for Plymouth Torbay and South Devon 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. http://Awww.legislation.qgov.uk/ukpqa/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 16/06/2015 | commenced an investigation into the death of Doreen Willis, 80. The investigation concluded at the end of the inquest on 6 June 2017. The conclusion of the inquest was NARRATIVE The deceased has a history of strokes due to clotting. Her risk of stroke was approximately 9% per year. This risk was mitigated by taking the medication Rivoroxiban For a period of time she did not receive Rivoroxiban. The absence of Rivoroxiban may have contributed to her death. She died at Belle Vue Care Home, Paignton on 9 June 2015. Massive Cerebral Vascular Accident CIRCUMSTANCES OF THE DEATH Reporting as safeguarding issues (as discussed by next of kin originally).Lady was admitted to TBH on 17/05/15 with a stroke then transferred to Brixham Hospital on 22/05/15. On 03/06/15 she was discharged to Belle Vue for end of life care. Prior to that she had been at Primley Court Nursing Home since 02/04/15 having been discharged there from Brixham Hospital. Vaguely aware that at Primley Court she was not given her Rivoroxiban. Had been seen by her previous surgery and notes not yet with new surgery HE states cause of death ista) Stroke learning points. 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. — At the conclusion of the Inquest | asked who presented evidence in connection with the Root Cause Analysis Report to summarise the key areas of learning identified. | am attaching her letter to my office of the 22 June 2017. | would ask you please to have regard to those recommendations when your organisation carries out future inspections of care homes. Would you kindly review the nature of CQC inspections in the light of «cy 1 Derriford Park, Derriford Business Park, Plymouth, PL6 5QZ Tel 01752 204636 | Fax 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 5 September 2017. |, 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 Mardy Farm House, Hengoed, Oswestry SY10 7EY. | have also sent it t orbay & South Devon NHS Foundation Trust, Torbay Hospital, Lawes Bridge, To! TAA | 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 responge by the Chief Coroner. Dated 11 July 2017 Signature for Plymouth Torbay and South Devon 1 Derriford Park, Derriford Business Park, Plymouth, PL6 5QZ Tel 01752 204636 | Fax
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 Torbay and South Devon 4.0 JUN 2017 NHS Foundation Trust c/o Legal Services Torbay Hospital Lawes Bridge Torquay Mr lan Arrow TQ2 7AA H M Coroner Torbay and South Devon 1 Palk Street Tel: 01803 652588 Torquay Devon TQ2 5EL Our ref: Your Ref: Date: 22 June 2017 Dear Mr Arrow Following the inquest held on 5" June 2017 in relation to the death of Mrs Doreen Willis, you have requested that the key learning outcomes pertaining to the care homes which were identified from the multi-agency review are summarised. This will enable you to provide a report to the Care Quality Commission (CQC) sharing the learning that can be taken forward by care homes in relation to the medicines management processes within their settings. Please find below the key areas of learning identified: e Care homes must have appropriate medicines management policies and processes in place to ensure the timely and safe ordering, receipt, administration and recording of medicines management for their individual residents. This should include all aspects of medicines reconciliation at each point or care transfer/transaction. e All staff within the care home involved in medicines management, including administration, are responsible for monitoring and checking the availability of ALL medicines required for individual residents. Where a medicine is not available for administration there must be a clear process understood by all staff, of what actions and recording of actions should be taken to ensure the medicine is obtained as soon as possible. e All actions in relation to medicines management must be recorded in the individuals care record and when a residents care transfers to another care provider the manager or responsible person should co-ordinate an accurate listing of all the resident's medicines as part of the onwards needs assessment and care plan. e NICE guidance SC1 provides recommendations for good practice on the systems and processes for managing medicines in care homes and care homes should ensure their policies and processes align with this. https://Awww.nice.org.uk/quidance/sc1 e The introduction of Electronic Transfer of Prescriptions (EPS) systems are now being introduced across primary and community care settings and this reduces the risk of error at points of transfer/nandover. This system reduces the need for fax or paper transfers and gives a full audit trail for each individual prescription. Care homes should be recommended to utilise electronic methods for ordering, receipt and reconciliation of medicines as a way of promoting resident safety in effective medicines management. We hope this information provides you with the key learning from the multi-agency review undertaken. Yours sincerely bebe! Lead Investigator on behalf of Torbay & South Devon NHS Foundation Trust Cc Devon & Cornwall Police Karen Ford, Quality & Safety Lead, NHS England, South (South West)
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