Joan Osborne

Adbolton Hall Ltd 

6-7 Keypoint Office Village, Keys Road 

Off Nixs Hill, Alfreton, Derbyshire, DE55 7FQ 

Response to Regulation 28 

 ‘Report to Prevent Future Deaths’ 

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- Operations Director for Adbolton Hall Ltd. I have been asked to submit 
I am 
this response by Jane Gillespie-Assistant Coroner, in response to a Regulation 28 – Report to 
Prevent Future Deaths following the inquest into the death of Mrs Joan Osborne. 

On  behalf  of  everyone  at  Adbolton  Hall  I  wish  to  again  express  our  condolences  to  Mrs 
Osborne's family. 

Set out below is our response to those specific concerns identified by the Assistant Coroner 
for Nottinghamshire. 

In addition to those actions outlined below, in the time after Mrs Osborne's death there has 
been a period of significant change at Adbolton Hall. On 6 November 2017 
was  appointed  as  the  new  Home  Manager,  since  then,  bringing  about  significant 
improvements in the service provided to all residents. 

The improvements relate to all those of concern identified by the Coroner but also extend 
beyond this to all aspects of the service provided at Adbolton Hall. 

As  a  Registered  Provider  of  Care  Services,  we  take  this  responsibility  seriously  and  are 
committed to the care of all residents at Adbolton Hall. 

Coroner’s Concerns: 

During the inquest the evidence revealed matters giving rise to concern in that there is a risk 
that future deaths could occur unless action is taken, as follows: 

(1) The nursing home staff did not seek assistance from the Dementia Outreach Team 
when Mrs Osborne’s compliance with her blood glucose levels and insulin prescription 
deteriorated at the end of 2016 onwards 

(2) The nursing home did not make any members of staff available for the pre-arranged 
appointment  with  the  Diabetes  Nurse  on  28/11/2016,  resulting  in  a  missed 
opportunity to seek assistance with Mrs Osborne’s compliance 

(3) The nursing home staff did not seek medical assistance for Mrs Osborne when she 
refused  to  have  her  insulin  prescription  over  an  extended  period,  on  two  separate 
occasions, leading to her hospitalisation on 12/08/2017 and 22/08/2017 

(4) The nursing home staff did not alert anyone in the management team to the fact that 
Mrs Osborne had refused to have her insulin prescription for a period of 3 days prior 
to her hospitalisation on 22/08/2017 

(5) The nursing home records in respect of Mrs Osborne were inadequately completed 
(6) The nursing home staff did not recognise the need, nor seek help, for Mrs Osborne’s 
deteriorating condition on 22/08/2017 and did not seek the urgent attention of her 
GP upon his usual attendance at the home on that date 

(7) Mrs Osborne was incorrectly given Lucozade on the morning of 22/08/2017 at a point 

when her blood glucose levels had not been obtained, and were ‘HI’ 

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 (8) A member of staff at the care home was unable to accurately maintain Mrs Osborne’s 
blood glucose level on 22/08/2017 when asked by the GP and did not recognise that 
the reading was incorrect       

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Response to Concerns: 

(1) Since the appointment of the new Home Manager,

, and the new Deputy 
Home Manager, 
, at ‘Adbolton Hall’, the nursing home staff now seek 
regular assistance from the Dementia Outreach Team. This assistance is sought as 
and when required, however on average takes place a minimum of once a month, 
ensuring regular communication with this Team. This can be evidenced upon review 
of  the  Professional  Visits  Book  and  Multi-disciplinary  Team  Communication  Sheets 
where applicable in residents' care plans.  

The Home Manager monitors the involvement of the Dementia Outreach Team with 
all residents who have been referred to them to identify any issues requiring a review 
of  care  provision.  The  Home  Manager  has  spent  time  building  a  positive  working 
relationship with the Dementia Outreach Team, which is mutually beneficial to both 
parties, and ensures that residents are referred and seen appropriately. Relationships 
have been strengthened with 
 (Occupational 
Therapist) and 

 (Assistant) of the Dementia Outreach Team. 

 (CPN), 

(2) The nursing home ensures always that members of staff are made available for all 
pre-arranged appointments with all Multi-disciplinary Team staff members which are 
diarised  in  the  Home  Diary  situated  within  the  office.  The  home  ensures  that  the 
Nurse-in-charge,  Care  Co-ordinators  or  the  Home  Manger  are  available  for  these 
appointments.  There  have  also  been  occasions  when  Multi-disciplinary  Team 
professionals have visited ‘Adbolton Hall’ unannounced, and staff have always been 
made available to see them. 

(3) The nursing home staff have received Nutrition and Diabetes Management Training. 
There were three separate sessions of this training, delivered at ‘Adbolton Hall’, on 
the 30/10/2017, 07/11/2017 and 30/11/2017. This training was delivered by 

 a Community Dietician from the Clinical Commissioning Group. This training 
included Management of Type 2 Diabetes, Treatments of Hypoglycaemia and Dietary 
Needs.  

Care planning with regards to diabetes management has been prioritised, as part of 
the  lessons  learned,  and  where  required  care  plans  include  details  with  regards  to 
when  and  how  to  seek  medical  assistance  if  insulin/medication  is  refused  by  a 
resident. 

For  all  residents  who  were  admitted  to  ‘Adbolton  Hall’,  with  complex  needs  (this 
included any resident who is diabetic), until recently the Home Manager ensured that 

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,  Management 
their  pre-admission  assessments  were  sent  to 
Officer for the Quality and Market Management Team within Nottinghamshire County 
Council, and 
, Care Home Quality Lead Nottingham North and East, 
Nottingham West and Rushcliffe Clinical Commissioning Group, to ensure that they 
were confident that the home could meet each individual’s needs. On 26 March 2018, 
 advised the home that they were not required to continue to send 
these to them, as they were satisfied that all the home’s admissions, including those 
with  individuals  with  complex  needs,  were  safe.  We  are  confident  therefore  that 
diabetes care is adequately assessed and provided for. 

In  addition  to  this,  new  Blood  Glucose  Monitoring  Machines  were  purchased  for 
individual residents on the 13 October 2017 to replace previous machines in use within 
Adbolton  Hall.  Staff  have  received  training  in  the  use  of  these  new  Blood  Glucose 
Monitoring Machines. 

(4) The Home Manager has ensured that she receives a daily handover with regards to 
all residents at ‘Adbolton Hall’. The process regarding handover has been reviewed 
and  revised  by  the  Home  Manager,  to  ensure  that  there  is  a  greater  volume  and 
availability of written information. This includes a daily handover sheet, printed sheets 
for all care staff to carry with them on shift and care charts for all residents.  

(5) Care plans with regards to diabetes management are now prioritised and reviews of 
care plans are directly monitored by the Home Manager and Deputy Home Manager, 
to ensure that the records are adequate.  

(6) Diabetic  charts  are  now  put  with  the  Medication  Administration  Record  sheets, 
ensuring that they are in constant use and are used as a reference point. Instructions 
on these charts are written in red and are updated by the Nurses if the GP alters any 
care instructions. All care charts now also physically go with the residents wherever 
they  are  in  the  home.  This  helps  to  ensure  that  care  charts  are  being  completed 
accurately, in a timely manner and improves communication amongst staff. 

(7) I refer to the points 3 and 4 above.  

Additionally, on the 20 March 2018 the Home Manager met with the GP who visits 
Adbolton Hall to outline those many improvements that have been made as detailed 
above.  This has provided valuable oversight and input from the GP and the Home 
Manager has also asked that he make her directly aware of any issues or concerns 
that he may have in the future. 

(8) All Lucozade has been removed from the building, and fresh fruit juice is now given 
if a resident is experiencing hypoglycaemia (determined by an accurate blood sugar 
reading.),  as  instructed  in  the  training  mentioned  above.  The  Lucozade  on  the 
22/08/2017 was given by a Senior Care Assistant and not a Nurse. In conjunction with 
the care plans for residents with diabetes, it is now clear that intervention with these 
residents is always nurse-led, and not carer-led. The care home also now has a very 

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stable Nurse team, of permanent staff, which helps to ensure that interventions made 
with residents are safe and correct.   

(9) New Blood Glucose Monitoring Machines were purchased on 13/10/2017, and staff 
have  had  their  competency  assessed  for  using  these  machines.  The  incident  with 
regards to the incorrect reading of the blood sugar on the 22/08/2017 was isolated 
to one staff member who has not worked at Adbolton Hall since the 22/08/2017.   

Since this incident, there have not been any further incidents where this has occurred. 
The home can additionally evidence that the one resident currently in the care home 
who is an insulin-dependent diabetic, has their diabetes well managed, and there have 
been no concerns raised by any agencies with regards to their care. 

Timescale for Action: All steps already implemented, and to be kept under ongoing review. 

I trust that the above provides a comprehensive summary of our response to those matters 
of concern outside within the Prevention of Future Deaths Report. 

As  set  out  above  we  have  taken  the  opportunity  to  learn  valuable  lessons  from  Mrs 
Osbourne's death to improve the standard of care provided to all residents at Adbolton Hall. 

Most importantly, we are confident in saying that the steps put in place will ensure that such 
an incident does not happen again. 

Yours sincerely 

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