Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0128A, written 17 Apr 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Apr 2019 |
|---|---|
| Reference | 2019-0128A |
| Deceased | Patrick Kelly |
| Coroner | Abigail Combes |
| Coroner area | South Yorkshire (West) |
| Category | Care Home Health related deaths |
| 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 2 3 4 5 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS This report is being sent to: Roseberry Care Centres, Haythorne Place, 77 Shiregreen Lane, Sheffield,S5 6AB CORONER Abigail Combes, Assistant Coroner for South Yorkshire (West) 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. INVESTIGATION In June 2018 I commenced an investigation into the death of Patrick Kelly. The investigation concluded following an inquest on 31 January 2019 where the conclusion was: Natural Causes CIRCUMSTANCES OF THE DEATH Patrick Kelly died as a result of sepsis part of which was as a result of a dental abscess. He was not compliant with dental hygiene and whilst it was this lack of compliance which contributed to the dental abscess; those providing care to him did not do everything in their power to ensure opportunities to improve his dental care were provided. He missed dental appointments and these were not rearranged with the care provider evidently placing little priority on the provision of dental care to their resident. CORONER’S CONCERN During the course of the investigation my inquiries revealed matters giving rise to a 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 – a) Roseberry Care Centres do not place adequate weight on the importance of dental hygiene and the provision of dental services to their residents. This has potentially resulted in the worsening of a dental abscess in one case. b) Roseberry Care Centres do not have adequate policies in place to deal with missed dental appointments and the identification of when dental appointments may be required. ACTION SHOULD BE TAKEN 6 In my opinion action should be taken to prevent future deaths and I believe you, the named organisation have the power to take such action. 7 8 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 14 June 2019. I may extend this period upon request. 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 I have sent a copy of my report to the Chief Coroner and to have also been sent to Sheffield City Council . Copies 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. Abigail Combes 17th April 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.
‘KECEIVED R 14 JUN 2019 iC Roscherry Care eer Ms A Combes HM Assistant Coroner The Medico- Legal Centre Watery Street Sheffield S3 7ES 12! June 2019 Dear Ms Combes Re: Patrick Kelly (deceased) Further to the conclusion of the above inquest and your subsequent letter dated 17 April 2019 and your request for a Regulation 28 report, please find our response below which details what actions we have taken in light of the findings and recommendations: We have implemented a Resident of the Day procedure whereby each day of the month a resident is identified as Resident of the Day and the care file is updated that day, involving the resident and / or relative. All care plans are reviewed and evaluated a minimum of monthly and staff seek feedback from the residents and / or the relatives at that time to ensure they are Updated regarding the health and well being of the resident as part of this process. The Home Manager then checks the care plan before close of business that day to ensure the file is uodated and includes evidence of resident and / or relative involvement. As part of the care planning process we have implemented a diary record to capture, at a glance, the dates residents last received dental care. Regrettably we do experience residents living with dementia are often resistive to the delivery of care and intimate treatment such as oral and dental care, the Resident of the Day procedure and the dental diary will highlight to the Home Manager when appoinimenis are due and alert her should appointments be missed due to residents reluctance to attend. This will ensure prompt action and / or advice is sought from the dental practice. Staff have attended training provided by the Clinical Commissioning Group which has enhanced their knowledge and awareness of potential issues with dental hygiene of our vulnerable residents so they know when to refer to the dental practices. We are seeking further training to be rolled out to the remaining staff. We have implemented these changes across our Group of care homes. Should you require any further information or clarity please do not hesitate to contact me at your convenience. Yours sincerely Director of Operations & Compliance Directors: J Murphy (Executive Chairman} M Dumble (Director) M Auckland (Director) Company Secretary: M Summerson Company Registration Number: GB 6281674 ROSEBERRY CARE CENTRES GB LTD Ast Floor, Valley View Care Centre, Penshaw, Houghton-Le-Spring, Tyne & Wear, DH4 7ER t: 0191 549 0506 f 0191 385 4001 head: www. roseberrycarecentres co.uk @roseberrycarecentres.co.uk
See every Prevention of Future Deaths report matching Care Home Health related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.