Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0294, written 3 Sep 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Sep 2018 |
|---|---|
| Reference | 2018-0294 |
| Deceased | Doris Douthwaite |
| Coroner | Chris Morris |
| Coroner area | Manchester South |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: Mr Justin Hutchens, Chief Executive, HC-One Ltd, Southgate House,
Archer Street, Darlington, County Durham, DL3 6AH
CORONER
tam Chris Morris, Area Coroner for Manchester South.
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 13™ March 2018, Rachel Galloway, Assistant Coroner, opened an Inquest into the death of Mrs
Doris Douthwaite, who died at Willow Wood Hospice, Ashton-Under-Lyne on 26" February 2018,
aged 93 years. The investigation concluded at the end of the Inquest which | heard on 28" August
2018
At the end of the Inquest, | recorded a narrative conclusion that Mrs Douthwaite died as a
consequence of bronchopneumonia. Whilst she would have been at risk of developing this
condition in any event, it is likely that her death was contributed to by a hip fracture sustained in a
fall at her care home.
CIRCUMASTANCES OF THE DEATH
Mrs Douthwaite had a complex medical history which included atrial fibrillation, a previous
myocardial infarction and type 2 diabetes mellitus. She was formally diagnosed with vascular
dementia in 2016.
Mrs Douthwaite’s mobility had become somewhat impaired in recent years — a particular feature of
this was falls from time-to-time associated with her being either light-headed on standing up or her
legs simply giving way.
{n December 2017, Mrs Douthwaite moved Greatwood House Residential Care Home in Denton,
Tameside. Greatwood House is currently owned and operated by HC-One Ltd.
Whilst at Greatwood House, the evidence before the court was that Mrs Douthwaite had 3 falls
between 11" — 13" February 2018. The first occurred whilst she was walking with a Zimmer frame
(but without assistance from a carer, contrary to the requirements of her care plan}, the second in
circumstances when she and other residents had been left unsupervised in a communal area whilst
the staff on duty attended to another resident, and the third when she was found on the floor near
her bed.
Mrs Douthwaite was subsequently taken to hospital where a hip fracture was diagnosed, and further
tests demonstrated that she was likely to have also suffered a stroke in the preceding weeks. Asa
result of raised inflammatory markers, Mrs Douthwaite was treated with intravenous fluids and
antibiotics.
In hospital, it was considered that Mrs Douthwaite was not fit enough to withstand an operation to
fix her hip fracture, and she developed pneumonia despite antibiotic therapy.
Mrs Douthwaite was moved to Willow Wood Hospice, where she died on 26" February 2018. The
Medical cause of her death was:-
1a) Bronchopneumonia;
\l) Vascular dementia, myocardial infarction, cerebrovascular accident, fractured left hip
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 before the court suggested that at Greatwood House, vulnerable residents
including residents with dementia such as Mrs Douthwaite, may be left unsupervised at
times in communal areas by carers undertaking other tasks. The evidence before the court
was that there are currently no clear written requirements in force across HC-One’s homes
mandating the attendance of a colleague to monitor the communal area in question before
leaving it unattended;
2. The Risk of Falls Assessment Tool currently used across HC-One’s homes was demonstrated
in court to be unclear and susceptible to different interpretations. When asked about it in
the course of her evidence, HC-One’s Area Director was not aware as to whether or not this
Assessment Tool had recently been benchmarked as against others used within the industry;
3. Notwithstanding the fact Mrs Douthwaite had 3 falls over the course of as many days in
February 2018, HC-One had not, as at the date of the Inquest, undertaken any investigation
into the circumstances of these. The absence of any investigation by HC-One in this respect
represents a missed opportunity to ascertain if any learning can be derived from these
incidents for the benefit of other residents.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you and your
organisation 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
29" October 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 Mrs Douthwaite’s family. | have also
sent a copy to Lester Aldridge, HC-One’s legal representatives.
| have sent a copy of my report to the Care Quality Commission and Tameside Metropolitan Borough
Council who may find it useful or of interest.
lam 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: 3" September 2018
a)
F,
Signature: 4-2, 4
Chris Morris im Area Coroner, Manchester South.
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