Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0377, written 6 Dec 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Dec 2018 |
|---|---|
| Reference | 2018-0377 |
| Deceased | Veronica Gregory |
| Coroner | Nigel Meadows |
| Coroner area | Manchester City |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: e > irectors of Zinnia Healthcare Limited e Suite 10, 792 Wilmslow Road, Manchester, England, M20 6UG Copied for interest to: e Chief Coroner e Next of kin e Cac CORONER : | am Nigel Meadows HM Senior Coroner for the Manchester City area. 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. INQUEST ! concluded the inquest into the death of Veronica Gregory on 28'" November 2018 and recorded that he/she died from: 1a Hospital acquired pneumonia b Right neck of femur fracture (operated) c i. Acute kidney injury je CIRCUMSTANCES OF THE DEATH The deceased was 83 years of age who suffered from dementia, lacked Capacity and was living in Yew Tree Manor Nursing and Care Home which is owned and operated by Zinnia Healthcare Limited. She moved into the premises in October 2013 but her condition so far as dementia was concerned continued to deteriorate. Although she was still mobile she suffered a number of falls over a period of time. On 14th September 2017 she fell again but this time suffering traumatic injuries to her face. It does not appear that a doctor was called to assess her and there were no records of any detailed physical examination or recorded observations for a period of time thereafter. The family were concerned about the apparent lack of review of any falls risk assessments together with supervision by care staff of the deceased. The deceased was in the habit of wondering around the care home during the majority of the day but also at night and was largely unobserved by the care staff during the day. Her care plan was apparently last reviewed on the 22" August 2017 and was due for further review on the 11" October 2017. The deceased was assessed as lacking capacity and would require a DoLs. At times the deceased could become aggressive. On the 14" September 2017 a document titled ‘Personal risk assessment and behaviour development plan’ was completed. But this simply dealt with the deceased becoming spontaneously agitated sometimes aggressive but not the risk of falls. On the 16'* November 2017 the deceased was in the lounge area of Yew Tree Manor when she had what was described as an unwitnessed fall On 224 August 2017 she was assessed as being at high risk of suffering falls and this was a long term issue. There are no records of the care plan and risk of falls being reviewed and reassessed between then and the 11" October, nor between 11! October and 16!" November. The current Home Manager agreed and accepted that the records in this respect were inadequate and incomplete. On the 16'* November 2017 during the late afternoon at about 1700 hours one of the other residents in the home indicated to one of the care staff that the deceased ‘decided to sit on the floor’ but that she did not fall This was not recorded tn the daily records, Whatever incident occurred this was unwitnessed by any member of staff but the other resident was then able to provide any other particulars. The deceased was unable to explain what if anything had happened. She was then examined by a RGN Nurse who recorded in an accident report form that no physical injury was observed or that the deceased was apparently in pain No specific recording was made of exactly what examinations and assessments were performed nor of any neurological assessment or any plan for continuing observations. It was not recorded that the deceased was assessed for ‘leg shortening’ It was recorded that she was ‘assisted up’ but not to where For example her feet, a static chair or to a wheelcharr. The deceased’s family were not advised about the incident nor was there a request made of further observations overnight and no doctor was called. The then home manager has indicated in a statement that the deceased ‘was observed during the night for PAD checks every 2-4 hours and there were no unusual occurrences’. However, there are no written records of that The current Home Manager agreed and accepted that a GP should have been called at that stage The following day on the 17" November 2017 the deceased’s son visited the home in the morning, at about 11 00 am, and on arrival was told that the deceased was in pain and it took some time for the staff to get her up and ready for the day. She was brought to see her son in a wheelchair and he noted that she was obviously in pain. It was recorded in a report to the CQC that she showed no signs of pain or discomfort until she was assisted to stand after getting washed and dressed at about 11.00 a.m. This was not recorded tn the daily records The deceased would usually have been checked on and assisted to get up much earlier in the morning and then dressed This may have been at 8.00 am She was apparently suffering bruising to the face. The current Home Manager agreed and accepted that the GP should have been called as soon as that injury was noted The Home Manager at that time had called the GP to attend. On his arrival her performed an initial examination and immediately directed that an ambulance be called urgently. She was then taken to Wythenshawe hospital where she was diagnosed as suffering from a fractured neck of femur She underwent operative treatment on the 19" November 2017 which was technically successful but post operatively her condition deteriorated because she developed pneumonia. This was recognised and treated but her condition continued to deteriorate and she died on the 23" November 2017 At the inquest hearing on the 28" November 2018 the newly appointed care home manager attended but no other senior member of management staff nor any Director of Zinnia Healthcare Limited. The current Home Manager acknowledged that all qualified nursing staff have the obligation under the NMC Code of Conduct to make accurate and full clinical records of any examination or decision as to treatment They should also be aware of the NICE Guidelines on the identifications and management of head injuries There were no clear records of the deceased’s usual level of observations between about 9 00 a.m. and 6.00 p.m onadaily basis The examination apparently performed by the nurse on 16" November did not specify exactly what was involved and results, nor dealing with possible “leg shortening” The current Home Manager agreed and accepted that the clinical records were inadequate and insufficient Thereafter, they was a lack of detailed observation records from the early evening until the following morning. There was no clear record of exactly which member of staff found her and the precise time. On 17" November when the deceased was brought to the office, the Home Manager should have been aware of the previous day’s incident because of the completed accident report form. This should have resulted in an immediate call to the doctor and a review of the deceased’s condition, but this was not done. The current Home Manager indicated that between September and November 2017 there were inadequate numbers of staff employed at the Home and this led to a delay in reviewing every and reassessing care plans for all residents. She accepted that it is for the owners and operators of the Home to secure provision of adequately trained staff in the required number. She accepted that there were a number of failures to provide basic nursing and general care for the deceased In addition the recording keeping was very poor. She indicated that further steps had been taken to improve matters but there was a lack of specific detail. The current Home Manager indicated that they had now moved to a computer based recording system and then some training has been given to staff about this. However, she readily accepted that whatever recording system was operated it was entirely dependent upon the full, accurate and timely entry of all appropriate information. | 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 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. Inadequate and insufficient care plans including specific risk issues together with, a lack of appropriate review and reassessment either following an incident or as a matter or general practise. 2. A failure to have appropriate daily observation records fully completed. 3. A failure to ensure that full and appropriate clinical records of any physical examination and action taken as a result being made. In addition, failure to refer to appropriate NICE Guidelines and comply with them. 4. A failure to ensure sufficient numbers of adequately trained staff at all times. 5. A failure to ensure that agreed protocols for seeking specific medical help and assistance were followed in respect of specific incidents. 6. A failure to ensure adequate supervision and governance of all relevant staff 7. A failure to be able to demonstrate, even at the time of the inquest hearing, specifically what changes in practice and procedure had been made, and how the governance of the Home was being managed and regular checking of the quality of all records now being kept. 6 | 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 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely Monday 4" February 2019. |, 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 | have sent a copy of my report to the Chief Coroner and to Interested Persons | have also sent it to organisations who may find it useful or 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. | DATE: NAME OF CORONER: 6 December 2018 Nigel Meadows HM Senior Coroner for Manchester City Area el Meadows
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.
Head Office: Zinnia Healthcare Zinnia Healthcare Limited ae 792. Wilmslow Road, idsbury, re Manchester. Yew Tree Manor Nursing Home M206UG F.A.O. Nigel Meadows HM Senior Coroner 01-Feb-2019 HM Coroner’s Office Manchester City Area Exchange Floor The Royal Exchange Cross Street Manchster M2 7EF Re: Response to The Matters of Concerns (Regulation 28: Report to Prevent Future Deaths) 1. Inadequate and insufficient care plans including specific risk issues together with, a lack of appropriate review and reassessment either following an incident or as a matter or general practise. Care plans are now formulated to incorporate specific risk issues like falls; these are risk assessed and reviewed monthly. If a change had occurred since the last review, or occurs in-between this period, the risk is then assessed again with the new change(s) incorporated into the Resident's care plan. Care plans are now audited to ensure reviews are done and the risks identified are managed appropriately. Initial care plans are created by the Manager/Business Manager/Registered Nurses using the pre- admission information gathered from the resident/relative/previous placement, and these are then extended and updated using further information identified after admission following further assessment of needs, risks and resident preferences and wishes. Care plans are reviewed by the Registered Nurses/Team Leaders/Business Manager and are overseen by the Manager on a monthly basis. They are reviewed monthly or more often as needs change and are amended, resident wishes and preferences change, and families are kept aware of changes to treatment as appropriate. 2. A failure to have appropriate daily observation records fully completed. In addition to staff having been trained, they are reminded during staff meetings and one-to-one supervisions to record any incident/accident that occurs during their shift and to hand such over to the next shift. Staff member must be specific on the type of monitoring that they have undertaken following an incident or accident, e.g. vital signs and physical examination of the Resident. They are reminded that these must be recorded promptly and clearly. 3. A failure to ensure that full and appropriate clinical records of any physical examination and action taken as a result being made. In addition, failure to refer to appropriate NICE Guidelines and comply with them. From May 2018 several staff competency assessments have been completed. Also, supervision about record keeping have been completed. The Manager has discussed with registered nurses how to access relevant information on NICE guidelines (including NICE Guidelines on head injury), and these are available for staff to access at any time for reference. Yew Tree Manor is a trading name of Zinnia Healthcare Limited. Company Number: 02976391 Head Office Suite 10. 792 Wilmslow Road, Didsbury, Manchester M20 6UG 1of3 In addition to their professional training, all the nurses have access to a copy of the Clinical Procedures on the computer and a hard copy of The Royal Marsden Manual of Clinical Nursing Procedures both of which contain topics on falls prevention and what to do in the event of a fall and a falls protocol is in place and displayed for staff reference. 4. Failure to ensure sufficient numbers of adequately trained staff at all times. Between August and November 2017, there was a home manager, deputy manager and nurse manager employed in the home, and registered nurses and care staff on duty 24 hours a day. The Directors have always strived to maintain sufficient numbers of adequately trained staff at all times. The home now has in place a staffing dependency tool to meet the assessed needs of the Residents monitored by the present manager. The Home Manager calculates the number of care and ancillary staff required in accordance with Resident needs to cover the relevant shifts. On occasions when any of our directly employed staff, for one reason or another, is not available, the Manager, Deputy Manager, Business Manager, or most Senior staff on duty, calls one of the staffing agencies we use, to supply us staff in order that the absentee’s role is covered. Agency staff profiles are always seen by the home before they come to ensure that their training is up to date to meet the assessed needs of the home. The home has embarked on extensive recruitment programme and have now recruited more registered nurses and team leaders who are nurses undergoing the IELTS to support the nurses and care staff. The Directors have sought and been granted Home Office sponsorship licence for the home in April 2018 to recruit nurses and have since been on several foreign trips to recruit and prepare suitable candidates. Some of the identified suitable candidates are currently preparing for both the IELTS and CBT tests. The Directors sourced and procured a Mentorship update course for the Business Manager and a Mentorship course for the Registered Manager and encouraged both to enrol. Both the managers have enrolled on these courses in preparation for the arrival of the newly appointed foreign nurses. Upon commencement at the home, each nurse will be mentored by both managers, undergo a robust induction and training programme to ensure they are suitably adapted and skilled to meet the needs of our Residents. The home has implemented the use of a dependency tool provided by Manchester City Council (MCC). Dependency level is reviewed on a monthly basis (or more often if required) with necessary adjustments made in the rota in accordance with the assessed needs of the Residents in-house and using the MCC tool. 5. Failure to ensure that agreed protocols for seeking specific medical help and assistance were followed in respect of specific incidents. The home has through one-to-one supervisions, coupled with the Competency Assessments, given clear guidelines to staff on when to seek medical help, also to refer to NICE guidelines for support. There is a file of NICE Guidelines available and accessible for all staff. The home has implemented a falls protocol flow chart for further guidance. This is available for all staff to access and reference at any time. Yew Tree Manor is a trading name of Zinnia Healthcare Limited. Company Number: 02976391 Head Office Suite 10, 792 Wilmslow Road, Didsbury, Manchester M20 6UG 2 of 3 6. Failure to ensure adequate supervision and governance of all relevant staff. Supervision and competency assessments are conducted regularly with all staff in a robust fashion, and this comprises all areas of needs of the Residents. The home’s policies and procedures are discussed during one-to-one meetings, supervisions and staff meetings. 7. A failure to be able to demonstrate, even at the time of the inquest hearing, specifically what changes in practice and procedure had been made, and how the governance of the Home was being managed and regular checking of the quality of all records now being kept. The Manager during the period of August 2017 to October 2017, her deputy and Acting Manager are no longer in our employment. We are taking legal advice on the disciplinary measures with regards to the nurse on duty on the 16" of November as she did not properly hand over the incident which occurred during her shift. There has been change in management. A new Manager who is also a qualified nurse has been employed since February 2018. Changes to practice and procedures have been made: Manager’s daily walk around, accident and incidents reviews, daily checks, Resident of the day implementation, training of relevant staff is undertaken regularly and as when needed, internal documentation changed to online based, wider range of audits are now carried out. As Providers, we look at the Manager's monthly care plan audits. She carries out these audits in her capacity as the Manager and as a professional nurse to ensure that they include accurate levels of details, treatments or adjustments to reflect any changes in care needs. We visit the home and discuss the resident’s welfare regularly on the premises and over the phone and via e- mail. When not on the premises, we are available via e-mail and phone for the Manager and other staff The above information has also been passed to and reviewed by our CQC inspector and we continue to work with the local authority and external consultants to improve our service for residents. | hope it meets with your expectations. However, should you require further information please do not hesitate to revert to us. Kind regards a) Mi. Directors Zinnia Healthcare Limited Yew Tree Manor is a trading name of Zinnia Healthcare Limited. Company Number: 02976391 Head Office Suite 10, 792 Wilmslow Road, Didsbury. Manchester M20 6UG 3 of 3
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