Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0143, written 11 May 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 May 2018 |
|---|---|
| Reference | 2018-0143 |
| Deceased | Ahmed Tabeche |
| Coroner | Nadia Persaud |
| Coroner area | East London |
| 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.
Eastern Area of Greater London Coroners MISS N PERSAUD SENIOR CORONER Walthamstow Coroner's Court Queens Road Walthamstow E17 8QP Telephone 020 8496 5000 Email coroners@walthamforest.gov.uk REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT |S BEING SENT TO: | Operational Director, Twinglobe Care Homes Ltd, Regional Office, 58-62 Abbey Road, Bush Hill Park, Enfield, EN1 2QN CORONER |am Miss N Persaud Senior Coroner for Eastern Area of Greater London 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 17/02/2017, | commenced an investigation into the death of Anmed Amin TABECHE. The investigation concluded at the end of the inquest 3rd May 2018. The conclusion of the jury at the inquest was: The head injury sustained at St Ann's and the unsatisfactory assessments carried out during his stay at Aspray House contributed to the deterioration of his overall health and the insufficient guidance and supervision specifically relating to his feeding requirements all contributed to his death by choking. CIRCUMSTANCES OF THE DEATH Mr Tabeche had suffered a traumatic brain injury whilst an in-patient at St Ann’s Hospital on or around 30 January 2014. His condition following the brain injury required full time care. He was admitted to Aspray Care Home on 2 March 2015. He was cared for on a unit with qualified nurses and care staff. He was blind, bedbound and required 2 carers to assist with personal care. He had suffered from swallowing dysfunction after the brain injury and required full assistance with feeding. The swallowing dysfunction had rendered him at risk of choking. The care plans and risk assessment in the Home recognised the risk of choking. The care plan also provided that “family and friends informed about it [swallowing difficulty] advice to give only soft pureed diet”. There was no clear direction as to who could feed Mr Tabeche. There was no written record to confirm that visitors had been advised how to feed Mr Tabeche. On the 15 September 2016 Ahmed was being fed by one of his regular visitors. He was being fed vegetable soup, which contained pieces of vegetables. He began to cough whilst being fed the soup and care staff intervened. He was noted to be choking and the choking protocol was followed. Resuscitation was carried out by nursing staff and then paramedics. Sadly he did not respond. He passed away at the Care Home at 1344 on 15 September 2016. The cause of death provided by the pathologist was 1a choking in a man with old traumatic brain injury. 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 evidence given by the nursing staff and care staff who continue to work in the Care Home did not indicate a full understanding of the gravity of the risk of choking. Matters such as not causing offence to visitors or concern of turning the Home into a prison were quoted as reasons why food might not be fully checked. Care staff did not appear to appreciate that where a patient is at risk of choking, robust systems need to be in place to protect their lives. (2)I note that action has been taken by the Care Home to place more posters around the Home, informing visitors to notify the nurse in charge before giving food to the loved ones. | do not consider that this is sufficient to address the concerns that have arisen in this case. The visitor who had been feeding Mr Tabeche confirmed that he focussed fully on Mr Tabeche when he attended. He did not read posters which were located inside Mr Tabeche’s room. He was not given any written information on the risk of choking; the type of food that Mr Tabeche should receive, or how he should be fed. More robust, written procedures around visitors and the provision of food may assist in providing a safer environment. 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 6 July 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 | a | have also sent a copy to the CQC and the Director of Public Health who may find it of interest. | 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. 11/05/2018 Signature € | oo Miss N Persaud Senior Coroner Eastern Area of Greater London
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.
CDTWINGLOBE Your Ref: AT ASP Sept 16 58 Abbey Road 05" July 2018 ENT ON T: 0208 370 1750 Nadia Persaud cnowvinge com Walthamstow / East London Coroners Court Queens Road Walthamstow London E17 8QP By EMA‘, CN Dears Sirs, Re : Inquest of Ahmed Amin Tabeche Date of Incident : 15 September 2016 We write further to the Inquest of Mr Tabeche which concluded on 3" April 2018 and the Regulation 28 Report to Prevent Future Deaths. As a company we treat such matters very seriously and have moved swiftly to re-evaluate our policies and processes to ensure that we are providing the best possible care to our residents in the safest way possible. We enclose with this letter an action plan that we have formulated in respect of this tragic incident and have sought to address the areas of concern that you raise as swiftly as possible. In addition to the action plan we enclose: - Action Plan for Regulation 28 Order Choking Risk Assessment (refers to box 1 of Action Plan) - Choking and Aspiration Care Plan (refers to box 1 of Action Plan) - Aspiration Guidance (refers to box 2 of Action Plan) - Nutrition and Fluid Chart (refers to box 6 of Action Plan) - Nutritional Profile (refers to box 7 of Action Plan) - Leaflet for relatives and visitors (refers to box 8 of Action Plan) - Poster (refers to box 9 of Action Plan) - Deprivation of Liberty Screening Checklist (refers to box 10 of Action Plan) - Mental Capacity Assessment Record (refers to box 10 of Action Plan) - Best Interests Decision Form (refers to box 10 of Action Plan) - Visiting and Visitors Policy - Meal and Mealtimes in Care Homes Policy - Food bought in by Visitors Policy INVESTOR IN PEOPLE Rogiscered in Cardilf | Regeetered Humber 464 8705 For the avoidance of doubt, these changes have been implemented across our group of Homes. Should the Coroner require further clarification on the enclosures, please do not hesitate to contact Julie Burton, Operation Director. Julie.burton@twinglobe.com alternatively Mobile 07966487987. Yours Faithfully eye Head of Operations
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