Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0453, written 18 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 | 18 Jul 2017 |
|---|---|
| Reference | 2017-0453 |
| Deceased | Ivy Mitchell |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| 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: The Manager of Fairfield View Care Centre, The Chief Executive of Tameside Metropolitan Borough Council CORONER lam Alison Mutch , Senior Coroner, for the coroner area of South Manchester 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 INVESTIGATION and INQUEST On 27" January 2017 | commenced an investigation into the death of Ivy Mitchell. The investigation concluded on the 11" July 2017 and the conclusion was one of Narrative: Died as a result of natural causes with a contribution being made by injuries sustained in an accidental fall. The medical cause of death was 1a Left sided bronchopneumonia; i! _ Left subcapital fracture Circumstances of the Death Ivy Mitchell was a resident at a care home. She had a history of falls. On 29th December 2016 she had a fall in her room. She appeared to mobilise afterwards. On the evening of 29th December she said she felt unwell. On 30th December following a discussion with her GP, a taxi was called and she went to Tameside General Hospital. A subcapital fracture and pneumonia was diagnosed. She was initially too unwell for surgery. She was operated on, on 7th January 2017. She dislocated her hip on 19th January 2017 but was not suitable for further surgery. She began to show further signs of infection on 25th January 2017. She deteriorated and died on 26th January 2017. 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. — 1. The documentation relating to the falls risk was inaccurate. It did not refer to previous falls and did not reflect her mobility; 2. There was a lack of understanding amongst the care home staff of risk assessments; reviews and the required process following a fall. This included documenting observations after a fall. 3. Processes relating to escalation following a fall were not complied with; and 4. There was a lack of understanding of the trigger for a referral to the community nutrition team. 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 12" 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, CQC and to the following Interested Persons namely daughter of the deceased, who may find it useful or of interest. lam 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. Alison Mutch 0.B.E HM Senior Coroner 18" July 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.
FAIRFIELD VIEW CARE C EN TRE st ee 31° August 2017 | i, JBIVED Miss A Mutch erp on} HM Senior Coroner | (41 SEP col Coroners Court ee CH. 1, Mount Tabor Street a Stockport SKI 3AG Dear Miss Mutch Re: Mrs Ivy Mitchell I enclose my reply, in response to regulation 28 in the case of Mrs Ivy Mitchell. | have now audited ail the documentation in relation to falls and mobility of all the service users. In relation to Mrs Mitchell, | accept that the documentation and risk assessments did not accurately reflect her falls or mobility, which has caused me great concern. Senior staff attended the meeting held in relation to documentation and the falls procedure. Details of which, I enclose. This information has been cascaded down to staff, and the importance of completing all the relevant documentation was discussed at length. I have emphasised the failings in relation to Mrs Mitchell, and that we must ensure it does not happen again to any of the service users. | am now auditing all care plans and daily records on a daily and weekly basis, to ensure accuracy regarding risk assessments, and that documentation in the event of a fall is completed accurately and in a timely manner, Unit Managers, Deputies and Senior Care Staff are undertaking a course on care planning, this will commence in September of this year with Tameside College. This will include how to complete an accurate risk assessment as well as identifying the needs of the service user. This course will provide them with more knowledge about the importance of documentation and of the need to involve the service user, where there is capacity, or their relatives in all care planning activities. [have again made staff aware of the referral process that needs to be completed where there is. a cause for concer over the nutritional status of a service user. This is an area that | will also be auditing on a regular basis and giving advice about referrals where | feel it is necessary to do so. | have enclosed the nutritional referral form that is used by the Community Dieticians for all referrals in the community. te sage Fairheld View Care Cenure, 85 Manchester Road, Audenshaw, Manchester M34 5GB Telephone: 0161-170 6719 Fax: 0161-370 8429 1 et 1 remaee Dnwetors: | Awsedah, Ht, Meredah, & Mosedity (NVESTON IN tures, I hope my response addresses your concerns in relation to the regulation 28 notice. If you require any further information on this matter, please do not hesitate to contact me. Yours sincerely scam Manager Enc.
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