Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0104, written 11 Apr 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Apr 2018 |
|---|---|
| Reference | 2018-0104 |
| Deceased | George Goldby |
| Coroner | Jane Gillespie |
| Coroner area | Nottinghamshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. HC One (care of LA Law Solicitors) 1 CORONER I am Jane Gillespie, assistant coroner, for the coroner area of Nottinghamshire 2 CORONER’S LEGAL POWERS I 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. 3 INVESTIGATION and INQUEST On 03.04.2018 I commenced an investigation into the death of George Goldby, aged 63. The investigation concluded at the end of the inquest on 11.04.2018. The conclusion of the inquest was natural causes contributed to by neglect. 4 CIRCUMSTANCES OF THE DEATH George Goldby was admitted to Stoneyford Care Home on 31.08.2011. He had a medical history of hypertension, hypercholesterolemia, type II diabetes mellitus, transient cerebral ischaemia, cerebral atrophy, frontotemporal dementia and epilepsy. Mr Goldby was fully dependent on staff to meet his personal care needs, provide his medication and provide him with nutrition and fluids. On 22.10.14 Mr Goldby was assessed by I , Speech and Language Therapist who recommended the following: - One to one supervision at mealtimes to prompt swallowing/focus to task - Normal diet although chewy meat items to be pureed as a means of reducing the length of the oral phase - Thin fluids On 04.10.16 an unknown care assistant completed a choking risk assessment in respect of Mr Goldby and arrived at a high risk score of 80. This was not verified by a nurse and did not result in a re-referral to SALT, nor to a review of Mr Goldby’s care plan or dietary requirements. On 26.12.16 Mr Goldby choked during a mealtime and paramedics were called. He was not taken to hospital as he had recovered and the paramedics left at 2.06pm. Thereafter Mr Goldby was given chocolate bars, sandwiches and biscuits to eat. The choking incident was not entered onto Datix, nor was an incident and accident report completed. This incident did not, therefore, result in a re-referral to SALT or to a review of Mr Goldby’s care plan or dietary requirements. It was found during the inquest that a choking risk assessment was completed on 02.02.17 which resulted in a high risk score of 54. No re-referral was made to SALT at the time, nor was Mr Goldby’s care plan reviewed or dietary requirements considered. On 20.03.17 Mr Goldby choked on a sandwich. He was taken to hospital and died on 24.03.17. Following a post mortem examination the case of death was 1a. Aspiration Pneumonia 1b. Choking 1c. Dementia. Mr Goldby’s SALT recommendations were not being adhered to on either occasion when he choked, nor was the SALT assessment on his file when it was seized and sealed at the time of his death. There were three missed opportunities to re-refer Mr Goldby to SALT and to review his care plan and dietary requirements. At the time of his death, none of the staff who gave evidence at the inquest were aware of a SALT assessment, the needs for one to one supervision or any specific dietary requirements. 5 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 could 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 nursing home staff were unaware of the SALT recommendations regarding Mr Goldby’s need for one to one supervision and dietary requirements. (2) Mr Goldby’s SALT recommendations were not being adhered to on 26.12.16 when he choked and recovered, nor on 20.03.17 when he choked again, directly leading to his death. Mr Goldby was not supervised one to one during his mealtimes. (3) There were three missed opportunities to re-refer Mr Goldby to SALT and to review his care plan and dietary requirements. (4) The choking incident on 26.12.16 was not reported in line with Stoneyford’s internal policy. (5) The care plan records and in particular, the choking risk assessments in respect of Mr Goldby were inadequately completed and record keeping has been incomplete and/or wholly disorganised. (6) The SALT assessment in respect of Mr Goldby had been archived and was not present on his care plan file at the time of his death. (7) Staff at the care home remain unaware of how many residents are at high risk of choking and the need for supervision. (8) Between 19.09.17 and 18.10.17 three separate independent professionals observed residents at high risk of choking eating alone, without supervision. (9) On 05.04.18 a reviewing officer from Nottinghamshire Safeguarding Team attended at the home to do a spot check and reviewed 4 files. That check revealed a choking risk assessment in respect of one of those residents which was said by the officer to be inadequate, out of date and not fit for purpose. (10) Stoneyford care home currently has a CQC rating of inadequate, is in special measures and has a current restriction in place regarding the admission of any further residents. (11) Stoneyford care home has had a high turnover of managerial staff in the past year and this has resulted in a lack of consistency and stability. The role of home manager has yet to be permanently filled. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 06.06.18. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: – Mr Goldby’s wife Nottinghamshire County Council Older Adults Safeguarding Team Care Quality Commission Clinical Commissioning Group Previous Deputy Manager of Stoneyford Care Home ; Previous Area Operations Director of HC One Nursing and Midwifery Council I 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. 9 11.04.2018 Miss Jane Gillespie
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.
Ms Jane Gillespie Assistant Coroner The Council House Old Market Square Nottingham NG1 2DT 6 June 2018 Dear Ms Gillespie, | write to inform you of the actions taken at HC-One in response to Regulation 28 to prevent future death. Following the inquest into the death of Mr. Goldby, we at HC-One, undertook a full review of the systems and processes in Stoneyford care home and our organisation. We allocated an Operational Project Manager, whose role is to support the review of SMART actions stipulated within the Home Improvement Plan to improve and sustain positive outcomes for Residents safety and well-being at the home. This process enables the team in the home to make the changes without the additional administrative burden of managing the action plan and ensuring that there is robust follow up and escalation for any issues that are evidenced to be ‘off track’ with target. The Area Quality Director and Regional Quality Director attended Stoneyford and reviewed the care and support needs of each individual person accommodated and re-planned their care as appropriate. The following actions were taken: oS lie 1. Allocation of staff fo and practical supervision of Residents whilst eating and drinking to assess any issues. 2. Completion of the swallowing risk assessment with independent validation from another senior colleague to ensure accurate scoring and corresponding actions to mitigate risk are adhered to. This system remains in place with the Care Manager reviewing and signing off any updates. 3. All Residents whose assessment indicated having reached the appropriate threshold of need have been referred to the Speech and Language team (SALT) service via the GP for review- New referrals have also been actioned and follow-ups reviews have been planned by SALT- 2 existing Residents are due a review, which have been scheduled. 4. The Care Manager has taken responsibility for oversight of communication between SALT and colleagues at the home to ensure optimum communication and appropriate escalation for support. This has been reported by all parties as very much improved, with greater clarity and swifter partnership working. HC-One T 01325 351100 F01325 351144 Correspondence & Registered Office: Southgate House, Archer Street, Darlington, County Durham, DL3 6AH Registered in England and Wales: HC-One Limited, registration no. 07712656; Meridian Healthcare Limited, registration no. 01952719; HC-One Beamish Limited, registration no. 05217764; HC-One Oval Limited, registration no. 10257888; RV Care Homes Limited, registration no. 07417290. UF re company 5. All existing fluid/diet requirements from SALT were shared with the whole team of colleagues working at the home. This includes the catering team, as well as housekeeping, care and nursing colleagues to ensure that as one team, the staff act as additional eyes and ears to protect Residents and prevent harm. 6. Once this initial work was completed at Stoneyford, we sought advice from senior clinicians within the company for governance and oversight, which resulted in the care plans being rewritten to specify the detailed plan of care for each Resident. 7. Additional advice was sought from the company Hospitality specialist to establish if there were any further processes or mechanisms to help support the safe and effective management of people who require a specialist diet. As a result we have introduced a new system of dining registers with quick reference guides, which were put into place and help colleagues or any agency workers to reflect the handover documentation. These guides are reviewed fully every week, regardless if there are any changes, or immediately by the senior care staff, if any changes in a Resident’s health or needs have been identified. There is a formal update process in place and this is discussed daily at the flash meeting with a prompted question within the documentation in case it is someone unfamiliar with the process who leads this meeting. The governance for this is managed by the care manager and then the area quality management team as a further check. 8. The manager and staff at the home have implemented a ‘Resident of the day’ approach to care plan reviews which means that a designated Resident has their care and support needs reviewed every day to ensure any changes are reflected in updated care plans and shared with colleagues who support them. Any changes in need are reported monthly through to the clinical risk register, which is monitored by the Senior Turnaround Manager working at the home and the Area quality management Team. We believe that there is no substitute for repeated learning opportunities that help inform staff of the consequences of not supporting Residents effectively and to that end have commissioned a three day face to face dysphagia course for the staff team from an external expert training provider. This is to supplement and extend the learning opportunities already available and refreshed by the team via our online award winning learning platform, Touchstone. All colleagues working at the home have received supervision to support them with their working practices and which has led to the identification of any gaps in knowledge and sourcing of learning opportunities to support them in their roles. Areas covered have included understanding Resident's needs, identification of changing needs, escalation processes, role profiles for each specific job, responsibilities and accountability, the vision and values of the organisation and the prioritisation of the delivery of high quality and kind care. The hospitality specialist has supported the home and worked with colleagues working in the kitchen to implement and embed the policy and process that is required to be in place. oS AA Page 2 of 4 The Catering Manager in the home has developed their own review process for long term updates of diet notifications where Residents care needs haven't changed. The catering team have taken a proactive approach to the concerns raised. This process developed within Stoneyford will now form part of the governance strategy for managing the risk of choking across HC-One. We recognise the seriousness of the issues raised by the death of Mr. Goldby and correspondingly have committed considerable resources to give ourselves, the Resident, family and external partners and regulators trust and confidence that we can ensure the safety of all of the Residents who currently reside within Stoneyford. We continued, like many care providers, to find significant challenges in recruiting a stable nursing workforce and have addressed this through the cancellation of the regulated activity of nursing at this home. This is being processed by the CQC and will be completed when the final four nursing Residents are safely transferred to suitable alternative accommodation. We believe this will reduce the acuity of the people accommodated at the home and the inherent risks associated in managing care with a lack of stability in the nursing team. Whilst this process is being managed we have sustained senior management cover at the home 7 days a week to oversee the process. At this time there are 4 Residents currently requiring nursing care with expected safe discharge by end of June 2018 and subsequent closure of the nursing service. There is a registered manager in place who is a Senior Turnaround Manager and a newly appointed Care Manager whose background is in Residential care services. As mentioned, this team has been working across 7 days/nights to ensure that the actions we have planned are being progressed and embedded with the care team. CQC completed a comprehensive inspection at the home on 24 and 25 April 2018 and the final report has since been published. The previous report from the October inspection evidenced breaches on regulations around safe care and treatment of Resident, Need for consent, meeting people's nutritional and hydration needs, person-centred care and good governance. The April report has evidenced that all of these issues have been satisfactorily addressed, there have been significant improvements in the quality and safety of care and support, there are no regulatory breaches and resultantly the home has moved out of special measures with an improved rating. We believe that this has evidenced that the team in the home have worked with the people they care for and external professionals to achieve positive outcomes and is reflective that the actions have been achieved and that we continue to work towards ensuring the sustainability of all the learning, good practice and processes that have been refreshed at the home. | do hope that this response offers you sufficient assurance that we have acted with diligence, thoroughness and commitment to ensure the appropriate lessons have been learned and oS \L Page 3 of 4 bind © Campory, necessary actions taken to reduce the likelinood of any repetition of the tragic circumstances that lead to the issue of this regulation 28 report. Yours sincerely Head of Standards and Compliance Page 4 of 4
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