Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0166, written 28 Mar 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Mar 2018 |
|---|---|
| Reference | 2018-0166 |
| Deceased | Donald Martin |
| Coroner | Anna Crawford |
| Coroner area | Derby and Derbyshire |
| 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.
IN THE DERBY CORONER’S COURT IN THE MATTER OF: Inquest Touching the Death of Donald Martin A Regulation 28 Report — Action to Prevent Future Deaths 1 | THIS REPORT IS BEING SENT TO: Cecilia Banjoko RCN Legal Services Lyndon House 58-62 Hagley Road Birmingham B16 8PE Lindsey Foster General Manager The New Lodge Nursing Home 114 Western Road Mickleover Derby Derbyshire DE3 9GR 2 | CORONER Miss Anna Crawford, HM Assistant Coroner for Derby and Derbyshire 3 | CORONER’S LEGAL POWERS I make this report under paragraph 7(1) of Schedule 5 to The Coroners and Justice Act 2009. 4 |INVESTIGATION and INQUEST The investigation into the death of Mr Martin was commenced on 21 January 2016 and the inquest concluded on 14 February 2018. The cause of death was: la. Acute on chronic respiratory failure. 1b. Smoking-related Chronic Obstructive Pulmonary Disease exacerbated by aspiration of foreign material. The conclusion was ‘Natural Causes’. CIRCUMSTANCES OF THE DEATH Mr Martin was a 96 year old gentleman and a resident at Langdale Heights Nursing Home. He suffered from Chronic Obstructive Pulmonary Disease and was on long-term oxygen treatment. On 14 January 2016 he was observed by the nursing and care staff to be struggling to breathe. The Nurse in Charge contacted the ambulance service and Mr Martin was pronounced deceased shortly after their arrival. The court found that there had been a number of non-causative deficiencies in the emergency response provided by the Nurse in Charge prior to the arrival of the ambulance service. CORONER’S CONCERNS Nurse Cecilia Banjoko was the nurse in charge on 14 January 2016. During the course of the inquest she gave evidence that she no longer works at Langdale Heights Nursing Home and is now a nurse at The New Lodge Nursing Home in Mickleover, Derby. She gave evidence that since Mr Martin's death she had attended and completed practical training in relation to basic life support and cardio-pulmonary resuscitation (CPR). However, she also gave evidence that (i) she did not know then and still did not know why the ambulance controller had asked her to move Mr Martin from his bed to the floor prior to the arrival of the ambulance crew and (ii) she did not know how to deflate a patient’s mattress at the time of Mr Martin's death and was still unaware of how to do so. The MATTER OF CONCERN is: Iam concerned that Nurse Banjoko: (i) may not understand why or when it appropriate to carry out CPR ona flat service; (ii) does not know how to deflate patient mattresses in the event of an emergency. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that the people listed in paragraph one above have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed. COPIES l have sent a copy of this report to the following: Lorna Smith Langdale Heights Nursing Home Nursing and Midwifery Council Care Quality Commission The Chief Coroner Te ON 10 Signed: ANNA CRAWFORD DATED this 28th day of March 2018
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.
Royal College
of Nursing
The voice of nursing in the UK
Our ref: LC40816
Your ref: AC/00205-2016
15 May 2018
PRIVATE AND CONFIDENTIAL
FAO: Dr Robert W Thomas
Senior Coroner
Coroner's Court
St Katherine’s House
Roz Hooper
Principal Legal Officer and Solicitor
Royal College of Nursing
Lyndon House
58-62 Hagley Road
Edgbaston
Birmingham
B16 8PE
Rebecca Swinton-Bland
Legal Officer
Telephone: 0207 647 3445
Fax: 0121 450 4348
Email:Rebecca.Swinton-Bland@rcn.org.uk
St Mary’s Wharf
Mansfield Road
Derby, DE1 3TQ .
By First Class Post
Dear Dr Thomas,
Re: Regulation 28 Report to Prevent Future Deaths
Further to the Regulation 28 Report provided to Ms Cecilia Banjoko, please find
enclosed a copy of her reflective piece following the Inquest in this matter.
Please consider this as the member's response to the Action Points requiring
addressing within the Regulation 28 Report.
Within her response, Ms Banjoko explains the processes involved in performing CPR
in various circumstances, how to deflate a mattress in an emergency, and the
importance of deflating the mattress to ensure that CPR is performed on a fiat, hard
surface. Ms Banjoko is also aware of why there is a need to deflate mattresses in
emergency situations.
Ms Banjoko continues to remediate her practice and address any concerns there may
have been with her practice at the time of the incident and she continues to undertake
mandatory training and has completed basic life support training, including a practical
assessment in CPR (enclosed for the Coroner's attention).
The Coroner should also be aware that an NMC referral in relation to this Patient was
running concurrently with the Inquest in this matter, and has recently established that
there are no further concerns with Ms Banjoko’s practice and as such, there is no case
to answer and their case has been closed.
The RCN represents nurses
yo ala and nursing, promotes
President : _ excellence in practice and
Royal College of Nursing Patron . some
of the United Kingdom Her Majesty the Queen PG ee
20 Cavendish Square
London W1G ORN ye
Telephone +44 (0) 20 7409 3333 C@%ilia Anim RGN, DPSN | shapes health policies
RCN Direct 0345 772 6100 Chief Executive & General Secretary
www.tcn.org.uk Janet Davies BSc {Hons), MBA, RGN, RMN, FRCN
H
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i %, INVESTORS
yf IN PEOPLE
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The RCN is a Royal College set up by Royal Charter and a Special Register Trade Union
established under the Trade Union and Labour Relations (Consolidation) Act 1992.
Page 2 of 2
Yours sincerely
Rebecca Swinton-Bland
Legal Officer
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