Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0052, written 14 Feb 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Feb 2019 |
|---|---|
| Reference | 2019-0052 |
| Deceased | Douglas Minns |
| Coroner | Tom Osborne |
| Coroner area | Milton Keynes |
| Category | Emergency services related deaths (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This from is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Mr Richard Alsop, Chief Operating Officer, Milton Keynes CCG 1 CORONER I am Tom OSBORNE, Senior Coroner for the area of Milton Keynes 2 CORONER’S LEGAL POWERS I 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 23/08/2018 I commenced an investigation into the death of Douglas Albert Walter MINNS aged 93. The investigation concluded at the end of the inquest on 17th December 2018. The conclusion of the inquest was that the deceased died from an accident, namely the fall at home. 4 CIRCUMSTANCES OF THE DEATH The deceased suffered a fall at home, 2018 at 8.30pm in the evening and he made an emergency call to the ambulance service. He was attended to by the ambulance service at 00.25 on 22nd August 2018 and he was eventually conveyed to Milton Keynes University Hospital arriving at 02.08. A CT scan revealed a large subarachnoid and subdural bleed caused by the fall. He died at the hospital at 15.50 on 22nd August 2018. The delay in the ambulance attending was due to high operational demand. , on 21st August 5 CORONER’S CONCERNS The MATTERS OF CONCERNS are as follows: During the course of the evidence it was explained to me that the provision of a falls service was withdrawn some years ago, the service would provide for someone to attend the home of the person who had fallen, get them on their feet, assess their wellbeing, serve a cup of tea and get them back into bed if required. If they required more urgent treatment, they would report to the ambulance service. The withdrawal of the service puts patient’s lives at risk and, in view of the strains on the ambulance service, consideration should be given to re- introducing it. someone responds. It is unacceptable for a 93 year old man to be left lying on the floor for four hours before 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or 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 by 4th April 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons South Central Ambulance Service The Family of Mr Minns I have also sent it to the Chief Executive of Milton Keynes Hospital who may find it useful or of interest. I 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. 9 Tom OSBORNE Senior Coroner for Milton Keynes Dated: 14 February 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.
NHS Milton Keynes 28 March 2019 Clinical Commissioning Group NHS Milton Keynes Clinical Commissioning Group Coroner's Officer Sherwood Place HM Coroner's Office 155 lala Civic Offices % ee 1 Saxon Gate East pilion|Reynes Telephone: 01908 278685 MK9 3EJ Email: Web: www.mlitonkeynesccg.nhs.uk Dear Ms Toms Re: Regulation 28 Report to Prevent Deaths: Falls service Thank you for your letter received 18" February, concerning the fall and subsequent death of Mr M. Milton Keynes did have a falls service as you describe, some years ago. That service was superseded by a number of community based services that have been put in place to offer a targeted approach to individual situations. These include: A Home 1* Rapids service provided by our community provider, CNWL comprising of experienced nurse practitioners and prescribers, who respond to a call from a GP, ambulance services or other allied health professional. The service triages all cails within 15 minutes and has a 2 hour attendance requirement, unless advised otherwise by another health care professional who has seen the patient. In the majority of cases, attendance by Home 1* Rapids will result in the patient being assessed and made comfortable at home, avoiding a hospital attendance. Should transfer to hospital be necessary, the team calls for assistance or an ambulance according to the severity of the condition. This service operates 24/7, has approximately 1500 new referrals per year and is provided in people's homes including Care Homes. The Staying Steady service provided by CNWL therapists as part of their Home 1* function. It is intended for people usually over 65 who have, or are at risk of falling. The service works with individuals to improving balance, core strength, mobility etc. It is not an acute service, but takes referrals form GPs, hospital staff or self/relatives. The service assesses an individual's fall risk factors and works with them to make changes in their home environment where necessary, including providing adaptive equipment. They also investigate the circumstances surrounding a fall and develop a preventative action plan to increase confidence with walking and daily activities; as well as developing individual exercise programmes that they be undertaken at home to develop strength and balance. This service, operating in office hours, receives approximately 1600 referrals a year. e The MK Council's Falls Service provided by B-Well works with Staying Steady to provide assessment, treatment and advice to older people who have fallen, are at risk of falling, or are fearful of falling, in a supportive environment. People can be assessed in their own homes and where exercise classes are required these are available free of charge to help reduce the risk of falling and improve mobility and balance. | hope the above description of commissioned services provides suitable assurance that although the original falls services was discontinued, it has been replaced by a 24/7 Home ih Rapids service to deal with acute episodes of falling in the community; supported by two in office hours services which focus on prevention and non-urgent needs. The Home 1* Rapids service reflects the objectives of the original falls service in that they attend the home, carry out an assessment, make the individual comfortable and call an ambulance if required. Please do not contact me should you require additional information Yours sincerely Chief Operating Officer
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