Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0017, written 11 Jan 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Jan 2019 |
|---|---|
| Reference | 2019-0017 |
| Deceased | Ruth Gregory |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| 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: Registered Manager of Reinbek Care Home 1 | CORONER | am Alison Mutch, Senior Coroner, for the Coroner area of South Manchester 2 | 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 3 | INVESTIGATION and INQUEST On 4" July 2018 | commenced an investigation into the death of Ruth Gregory. The investigation concluded on 7 January 2019 and the conclusion was one of Narrative: Died from natural causes contributed to by the recognised complications of an accidental fall. The medical cause of death was 1a) Aspiration Pneumonia; Il) Infected Right Total Knee Replacement | 4 | Ruth Gregory had significantly reduced mobility following a fall resulting in | a total knee replacement. Subsequently she developed an infection in her | knee and was treated at Stepping Hill Hospital. She returned to Reinbeck Care Home where she began vomiting - suggestive of an upper GI bleed. She was readmitted to Stepping Hill Hospital where she deteriorated due to aspiration pneumonia and died on 2nd July 2018. 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. — The inquest heard that Mrs Gregory's had required the knee replacement _| after being knocked over by another resident in the care home. The inquest was told that residents were regularly left unsupervised in communal areas of the care home and that this meant similar incidents could reoccur leading to trauma and consequential death. There was no detail available at the inquest about how this risk was managed and arrangements to ensure supervision of communal areas. 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 8'> March 2019. 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the foliowing Interested Persons namel irs Gregory's daughter, 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. Alison Mutch OBE HM Senior Coroner 11.01.2019
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.
Borough (Core Head Office: Alison Mutch OBE Coroner's Court 1 Mount Tabor Street ? Acorn Business Park - eres R EC EIVED Heaton Lane - Stockport - SK4 TAS 11 FEB 2013 Telephone: 0161 475 0140 Fax: 0161 475 0164 Sawer er Web: www.boroughcare.org.uk Date 04.02.2019 Regulation 28 Report to Prevent Future Deaths RE: Ruth Gregory Dear Ms Mutch Thank you for your correspondence of the 11" January following the death of Ruth Gregory. Following the Inquest, | have taken on board your comments regarding the communal areas being left unattended. The fall happened in 2014 and at that time the staffing levels were considerably lower than they are today. This time last year January 2018 we increased the staffing levels in all our homes due to the dependency of the residents we are caring for. There are now 8 staff on shift 8am — 8pm including a deputy manager and senior carer. Monday to Friday there is also a Manager and an administrator. Seven days per week there are also housekeeping staff and catering staff. At night there are now 4 staff on duty including a senior carer, where there only used to be 3 staff. Whilst there may be occasions when the communal areas are unattended for short periods this has been significantly reduced by the increase in staffing levels. All residents have an individual risk assessment, and this would state if they were unable to be left unattended. As the majority of residents who live in Reinbek have capacity they would be able to use the nurse call system to contact the staff if they required any assistance. During busy times of the day or when care staff are assisting residents with personal care the deputy manager and the senior carer are around the communal areas administering medication or completing support plans. i § % INVESTORS Silver Borough Care Umited is on Industial cnc Provident Soclaty ‘yc IN PEOPLE Aegan Oey tear ies P Harton Lae Stockport Sk4 14S Registered number 27788R Head of Care er = Y, © Yy INVESTORS ncn coal tiring a) Stockport Ska 14S | hope that with the additional staffing hours that have been put into place since the fall and the addition of a deputy manager on shift every day, you can be rest assured that the communal areas are safe for our residents. Please do not hesitate to contact me if you need any further information. Yours Faithfully Vase Regstered number 277882
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