Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0035, written 6 Feb 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Feb 2018 |
|---|---|
| Reference | 2018-0035 |
| Deceased | Mavis Reeves |
| Coroner | Ian Pears |
| Coroner area | Bedfordshire and Luton |
| Category | Other related deaths |
| Organisation named | East of England Ambulance Service NHS 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 Bedfordshire & Luton
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT !S BEING SENT TO:
First Port Retirement Property Services Limited '
Marlborough House
Wigmore Lane
Luton
LU2 9EX
CORONER
lam lan Pears, Acting Senior Coroner for Bedfordshire & Luton
t y
(2 | 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:/Avww. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 |
hito:/Awww.legislation.gov.uk/uksi/2013/1629/part/7/made
i.
3 | INVESTIGATION and INQUEST
On 5 July 2017 | commenced an Investigation into the death of MAVIS JEANNE |
REEVES, 83 years old. The Investigation concluded at the end of the Inquest on
31 January 2018. The Conclusion of the Inquest was ‘natural causes’.
| 4 | CIRCUMSTANCES OF THE DEATH
On the 18 July 2017 at 08:52 hours the deceased pulled her Careline cord in her)
flat saying she had a dry mouth and was struggling to breathe. The Paramedics
i arrived in the car park at 08:55 hours but due to an automated entry system, and
obtaining a key to her flat, there was a delay in their reaching the deceased. The
Paramedics were with the deceased at 09:18 hours and performed CPR until
| 10:12 hours.
L i _.
5
| CORONER’S CONCERNS
During the course of the Inquest the evidence revealed matters giving rise to \
Senior Coroner, The Court House, Woburn Street, AMPTHILL. Bedfordshire, MK45 21IX
Tel 0300-300-6559 { Fax 0300-300-8267
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 foliows. —
(1) At the Inquest it was revealed that there are 4 ways a non-resident can
enter the building:
(a) By entering the room number on the keypad
(b) By using a code
(c) By pressing 2 buttons, namely “clear” and then “call”
(d) By being allowed in by a resident that was passing through the
entrance
The deceased did not answer the call; the code was not available to the
paramedic, who had arrived before it was forwarded to his car's
computer. In any event that which arrived was probably not the correct
code.
The “call” button is supposed to connect to the Emergency Call Centre,
but will not connect if the Careline has been pulled. In this case, the fact
that the deceased was still talking to the Careline Operator meant that
option (c) above was not available to the paramedic. This is because the
system in place is an analogue system and there is only one line going
from the building to Careline.
Evidence was heard that only 3% of Careline calls result in 999 being
called. The remaining 97% are non-urgent calls, accidental calls and
calls by residents who are lonely.
This means that access using option (c) could be deprived by anyone
else in the building using the system.
Further it means that once one resident is using the system that no other
resident can call the Careline, even if there is an emergency.
The scenario of a resident calling the Careline in an emergency and
staying on the line is understandable and cannot be that unusual.
It appears that a digital system wouid avoid these problems.
It is understood that for a digital system to be installed the residents must
agree to fund it, and that would then form part of the service charge.
My concern is twofold. First, do the residents know of the limitation within
the Careline System currently installed? Secondly, in the absence of an
upgrade to digital, plans need to be put in place so that the emergency
services can gain access without undue delay.
Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX.
Tel 0300-300-6559 | Fax 0300-300-8267
(2) The Inquest heard that the analogue system takes 90 seconds to
connect. The reason for this is because it is also sending data relating to
the caller to the Careline Operator’s Terminal. A digital system would
reduce that to 4 seconds.
My concern again is whether the residents know this. In cases where |
promptness is important 90 seconds can be the difference between life
and death.
(3) The key safe contains numerous keys including the master key. The
paramedic had difficulties identifying which was the master key. j
It is important that the keys be clearly labelled to avoid delay in the
emergency services gaining access.
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 13 April 2018. |, 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: QJ (niece of the deceased), East of England
Ambulance Service NHS Trust and to Appello Limited.
it appears to me that your residents need to be involved in deciding
whether to incur the cost of an upgrade. | have attached a redacted copy
of this Regulation 28 Report and | give permission, should you feel it
appropriate, to send the redacted copy to your residents either in person
or to each residence to be placed on a central noticeboard. i
Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX
Tel 0300-300-6559 | Fax 0300-300-8267
| | 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 06 February 2018
_ IAN PEARS
Acting Senior Coroner
Bedfordshire & Luton
Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX
Tel 0300-300-6559 | Fax 0300-300-8267
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.
IN THE BEDFORSHIRE AND LUTON CORONER’S COURT IN THE MATTER OF: The Inquest Touching the Death of Mavis Jeanne Reeves Response to Ian Pears’ Regulation 28 Report (Action to Prevent Future Deaths) From FirstPort Retirement Property Services Limited 1. 1.1 1.2 2. 2.1 2.2 INTRODUCTION This document sets out the response of FirstPort Retirement Property Services Limited (“FirstPort”) to paragraph 5 of Ian Pears’ Regulation 28 report dated 6 February 2018 (the “Report”). For the ease of reference the Coroners matters of concern detailed at paragraph 5 of the Report are set out below: 5(1) At the Inquest it was revealed that there are 4 ways a non-resident can enter the building: (a) By entering the room number on the keypad (b) By using a code (c) By pressing 2 buttons, namely “clear” and then “call” (d) By being allowed in by a resident that was passing through the entrance First, do residents know of the limitation with the Careline System currently installed? Secondly, in the absence of an upgrade to digital, plans need to be put in place so that the emergency services can gain access without undue delay. 5(2) The Inquest heard that the analogue system takes 90 seconds to connect. The reason for this is because it is also sending data relating to the caller to the Careline Operator’s Terminal. A digital system would reduce that to 4 seconds. My concern again is whether the residents know this. In cases where promptness is important 90 seconds can be the difference between life and death. 5(3) the key safe contains numerous keys including the master key. The paramedic had difficulties identifying which was the master key. It is important that the keys be clearly labelled to avoid delay in the emergency services gaining access. The above matters of concern are dealt with individually at paragraphs 2 to 4. PARAGRAPH 5(1) We will address your two concerns raised within this paragraph in turn. However, prior to addressing your concerns we would like to provide some background information regarding the system in place. UK-611129600.1 2.2.1 The LD3 analogue system currently in place was installed in September 2014 at a cost of £24,958.00. The system is an industry-accepted grade and recognised as fit for purpose. Others within in newly industry regularly constructed/refurbished residential facilities similar to the premises in question. the system install the 2.2.2 When the upgrade was completed in 2014, all residents were informed of how the system works and the various entry methods. The entry system is also discussed with new residents on their new resident induction. 2.3 First, do the residents know if the limitation within the Careline System currently installed. 2.3.1 To ensure that the residents are fully aware of how the current Careline System works we held a residents meeting on 4 April 2018. The findings contained within the Prevention of Future Deaths report were discussed with the residents as well as the possibility of a new digital entry system. The contents of the meeting was followed up in writing, the letter was provided to the residents on 10 April 2018. Within the letter the residents were advised that a further meeting would take place on 2 May 2018 should they wish to ask any further questions or raise any concerns regarding the entry system. 2.3.2 The residents discussed the option of changing the system to a digital system however they have confirmed that they are happy with the current system and do not wish to change from the current system. 2.4 Secondly, in the absence of an upgrade to digital, plans need to be put in place so that the emergency services can gain access without undue delay. 2.4.1 2.4.2 As set out within the Report, there are four ways for the emergency services to gain access to the premises as a non-resident. Whilst the system in place at the time of the incident is recognised as an acceptable and fit for purpose system, it is recognised however that on the day in question the code provided was not correct. The error was due to the Appello Careline Operator not being aware of the correct code required for the particular type of Tunstall installed. This was formally raised with the Monitoring Services Director at Appello Careline and a joint review, with ourselves, was undertaken to ensure that all of their systems contained the correct numbers/codes for all of the developments that we manage and for which they provide this service. We have ensured that the correct codes are now contained on their system and that all operators at Appello Careline will see the correct codes when they connect to a specific development. 2.4.3 Further, as set out in paragraph 4.1 the master key is now individually stored to ensure ease of access for any emergency services. 2.4.4 Whilst the system in place is of the required standard, we are committed to ensuring the safety of the residents and as such, we have looked into whether any further safety measures could be put in place to ensure that the emergency services can have access to the premises without delay. (a) Firstly, we looked into installing Safelink at the premises, which is a system for enabling access to the building for carers visiting a residential premises and a further service offered by Appello Carline. They have confirmed however that this is a rotating code, which they issue and which changes regularly and therefore it would not allow emergency services to access the building without first registering for a code. The system was not designed for UK-611129600.1 2 this type of interaction; it was concluded therefore that installing Safelink would not add a further method of entry for the emergency services. (b) Secondly, we looked into installing an emergency telephone line at the entry gate. Appello Careline has confirmed however that the number provided at the front gate is an emergency number that connects direct to them and is treated with the same priority and urgency as a fire call at the residence. Again, this would not therefore add a further method of entry for the emergency services. 3. 3.1 4. 4.1 PARAGRAPH 5(2) We set out our response in respect to communicating the potential limitations with the analogue system, as outlined by the Coroner, in paragraph 2.2 above. PARAGRAPH 5(3) At the time of the incident all keys were clearly labelled and stored in the key safe at the main entrance. The safe has a speech module and pull cord as is industry standard. However, we note the Coroners concern that despite this control measure the paramedic had difficulty locating the master key and as an additional control measure we have therefore separated this key from the bunch of keys and it is stored separately and prominently within the key safe. UK-611129600.1 3
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