Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0015, written 10 Jan 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Jan 2018 |
|---|---|
| Reference | 2018-0015 |
| Deceased | John Edwards |
| Coroner | Margaret Jones |
| Coroner area | Staffordshire (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.
for Staffordshire (South) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1 ‘Care Home Manager (sent to home address as care home now closed ) Independent Futures 3. —Community Disability Nurse CORONER | am Margaret Joy Jones, Senior Assistant Coroner for Staffordshire (South) 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://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 06/01/2017 | commenced an investigation into the death of John Keith Edwards, 64. The investigation concluded at the end of the inquest on 10.1.2018. The conclusion of the inquest was: Accidental death contributed to by neglect CIRCUMSTANCES OF THE DEATH The deceased was 64 years of age and had a medical history which included down’s syndrome, heart pacemaker, dementia, Osteoporosis and celiac disease. He was admitted to Southwinds Care Home Burntwood for respite on the 1** October 2016. His falls risk assessment was poor. He suffered 2 slip falls on the 2" and 3 October 2016 and 2 seizures on the 3 October 2016. No medical help was sought and thereafter he was largely wheel chair bound. Significant bruising was noted on the 8" October 2016. Subsequent docurnentation was retrospective and poor. An out of hours GP was called on the 13" October 2016. His symptoms were poorly relayed to the GP and he was told only about a suspected chest infection. He prescribed prophylactic antibiotics and advised urgent referral to his own GP. This was not done. There was no evidence of a skin care plan. District nurses were called in on the 24" October 2016 to attend toa significant pressure sore. He was found to be screaming in pain and with obvious deformity of lower limbs. He was admitted to Good Hope Hospital and diagnosed with an old left acetabular fracture, an old displaced right neck of femur fracture, bilateral pulmonary embolus, possible liver laceration, pneumonia, congestive cardiac failure , sacral and left thigh ulceration. The original fractures had occurred well before his admission to the home. However his subsequent rapid decline was due to a combination of the subsequent falls, seizures, reduced mobility and development of pressure sores in the home. He was discharged from the hospital to Hoar Cross Nursing Home Abbotts Bromley where he died at 22.41 hours on the 19" December 2016. 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. — No 1 Staffordshire Place, Stafford, ST16 2LP Tel 01785 276127 | Fax 01785 276128 (1) Southwinds Care home did not appear to be able to cope with Mr Edwards complex care needs. Consequently the original placement appeared to be inappropriate (2) The Care Home had an inadequate policy to deal with falls and no policy for pressure sore prevention and care (3) Care Home staff applied a seizure policy which was not specific to the resident. (4) Care Home staff failed to seek medical assistance following seizures. (5) Care Home staff failed to deal with significant bruising which developed 8 days after admission to the Care Home. (6) Care records were retrospectively filled in. (7) Staff and management failed to recognise and seek help for the residents deteriorating condition other than by way of an out of hours attendance when the GP was given minimal information and the urgent follow up request was not done. (8) Staff were unaware that medication brought in by the family was available to Mr Edwards, therefore it was not given. None was sought from the GP. (9) Non patient specific dressings were used on pressure sores. (10) A non-patient specific mattress was used on his bed. (11) Visits by the placement officer and disability nurse failed to identify Mr Edward’s deteriorating condition. 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 8" March 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons e sister of the deceased e Care Quality Commission e HE Staffordshire Police | 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. Dated 10 January 2018 Signature a= for Staffordshire (South) No 1 Staffordshire Place, Stafford, ST16 2LP Tel 01785 276127 | Fax 01785 276128
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.
Southwinds Limited 17 CHASE ROAD BURNTWOOD Nr. WALSALL STAFFS. WS7 ODS Telephone: BURNTWOOD 672552 Dear Coroner, Re: Mr John Keith Edwards , | | | | This is a response on behalf of Southwinds Limited to the formal Regulation 28 Report of Senior Assistant Coroner Mrs Margaret J Jones. Section 3. It is not sufficiently shown, and not accepted, that the death of Mr Edwards was contributed to by any neglect (and none is accepted) on the part of Southwinds. Section 4. Overall the Coroner did not fully or sufficiently take into account other evidence from Southwinds. Also, the situation between the time Mr Edwards arrived at Good Hope Hospital and when he was admitted (when a Senior Care Assistant stayed with him) and the overall time between admission and his death, and his immobility after leaving Southwinds. Disproportionate weight was given to evidence noted in the Regulation 28 Report, including matters that could not have had a bearing upon the cause of death. All of this undermines the causal connection suggested in the Regulation 28 Report. == : Section 5 ' 1. Southwinds were not given full pre-admission information sufficient for the care of Mr Edwards. Southwinds were severely pressured by Staffordshire Social Services to take Mr Edwards. There would normally have been an assessment visit, but Staffordshire Social Services insisted there was an emergency situation. 2. The falls policy was that all falls were recorded. If any injury arose the resident was taken to A&E, or other medical advice obtained. As to pressure sores, the policy was that there were checks on all residents and body maps made where necessary. If any sign of skin breakdown was found the District Nurse service was contacted and they took over care. 10. 138 . There was no seizure policy supplied upon admission. Southwinds general policy as to epilepsy was followed. Upon admission there was no indication that Mr Edwards had had seizures. If there is a history of seizures then it was usual for a specific policy for that resident to accompany upon admission, which would then be followed. Mr Edwards was not prescribed any epilepsy medication to the knowledge of Southwinds. Seizures were micronic and recorded and general procedure followed. The bruising was documented. No skin was broken, and Mr Edwards was observed. The only record that was not completed contemporaneously was an entry that the Doctor called as to the chest infection of Mr Edwards. This was made the following afternoon upon the staff member concerned coming on shift. Medical advice for Mr Edwards was sought at the appropriate time. The Doctor was provided with full information and all questions raised by him were answered. There is no recollection as to the out of hours Doctor suggesting any urgent referral and no documentation (other than a prescription — which was obtained straight away) was left by the Doctor All medication brought in by the family of Mr Edwards was entered in the MAR sheets and subsequently given to Mr Edwards as appropriate, and only by staff trained to administer medication. There was never any suggestion that the dressing applied for the comfort of Mr Edwards was in any way incorrect. There was never any suggestion that the mattress provided for Mr Edwards was in any way incorrect or improperly used. Section 6. As the proprietor of Southwinds | decided, after over 30 years of providing care, to retire, and accordingly, Southwinds closed in December 2017. In this circumstance there is no action that Southwinds can take. Yours sincerely, \ J |_| Si lo \
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