Gloria Mekins

arp) KU SOIVLERE PAKK

CARE CENTRE

1 Greenock Road
Hartlepool
TS25 4EU

/
6 HU 209 Tel: 01429 812288

10%, July 2019

Miss C Bailey

Senior Coroner for Teesside & Hartlepool
HM Coroner’s Office

Middlesbrough Town Hall

Albert Road

Middlesbrough

TS1 2Q]

Dear Miss Bailey,
Inquest into the death of the late Gloria Elizabeth MEKINS

This reply is in response to your letter of 28th, May 2019, which was sent to Rossmere
Park Care Centre with a Regulation 28 Report, in which you request details of any
actions taken by the Home regarding your concerns noted in the Report.

Although I have addressed your Matters of Concern below, the first point! must make is
that your assertion in point 4 - Circumstances of Death - that “staff attended and
believed she was choking” is incorrect as there is no evidence in any of the staff
statements (which were written soon after the event) that ANY staff believed she was
choking at the time of the incident.

MATTERS OF CONCERN:

1. The Health Care Assistant who initially discovered Mrs Mekins choking carried
out no first aid, nor did she take any action to try and clear Mrs Mekins’ mouth or
help improve her breathing e.g. back slaps or Heimlich manoeuvre.

The first point I would like to make is that the HCA who was first on the scene DID NOT
DISCOVER MRS MEKINS CHOKING. Her statement shows quite clearly that when she
attended Mrs Mekins’ room, which she did within seconds of the buzzer being sounded,
there were no coughing or choking sounds or any indication that the lady was choking.
Mrs Mekins was sitting in her chair but was not breathing.

The HCA had received First Aid training but, perhaps because this was the first time she
had discovered anyone not breathing, chose to ring the Emergency buzzer and summon
further help and/or attract the attention of the Nurse on duty. The Senior HCA arrived
at Mrs. Mekins’ room shortly before the Nurse and checked her pulse - but there was no
pulse to be found. When the nurse arrived - some 30 second later - she observed that
the lady was cyanosed and not showing signs of breathing, She checked Mrs Mekins’
airways with a loop and scoop motion and gave back slaps but neither of these actions
showed evidence of choking. She requested a member of staff to ring 999, When the
paramedics arrived, they also confirmed the airway was clear of any obstruction

2. There was confusion as to the existence of a DNACPR and this led to a delay in
the provision of first aid.

The home accepts that the HCA was not aware that a DNCPR was in place, but for the
reasons explained above, did not attempt CPR. The Senior HCA who was next at the
scene was aware of Mrs Mekins’ DNACPR notice but needed to confirm the Notice was
still in date which it was. It was during the time of this check that the nurse carried out
her own actions and, being advised a DNACPR was in place and was extant, requested
an ambulance.

Staff are advised which resident has a DNACPR Notice by means of a whiteboard within
the Nurse’s office at Rossmere Park Care Centre - with the same facility in the Senior's
office on the Ground Floor. This shows against each resident's room, whether a DNACPR
is in place and the date it expires. The Daily Handover sheets also show clearly against
each room which resident has a DNACPR.

Immediately following the Coroner's Inquest on 17*, May 2019, the home implemented
a new system to notify staff which residents hold a DNACPR Notice. Where a DNACPR is
in place for a resident, a Blue Butterfly has now been attached to the outside of the
resident's room door near the resident's photograph. An Advice notice (that a DNACPR
is in place) in bold, red writing has also been placed at the front of the black folder kept
in each resident’s room where staff write daily and visual observations and so is in
constant use by all care staff.

3. The Care Home had not undertaken an internal investigation into events
surrounding Mrs Mekins’ death and have not identified the above issues, nor
have they attempted to remedy them.

Immediately following the death on 2" October 2018, | asked all staff involved to write
a Witness Statement whilst the events were fresh in their minds as | was due to goon
annual leave the next day. Whilst I was away, a call was received from your office
advising that Mrs Mekins’ death was due to choking.

Before I went on leave I was aware from conversations with the HCA, SHCA and RGN
that there was no evidence of choking, there was a DNACPR in place, the lady’s

“Choking” risk assessment had shown she was not at risk of choking and she had never
needed to be referred to the Speech and Language Team (SALT) and that she was
frequently brought food by her family which she regularly ate in her room without
incident. I was also aware that both emergency services had visited and had shown no
concerns.

As a qualified nurse and Registered Manager of many years, I was also drawing on my
past experience and had never been asked to conduct a formal investigation following a
sudden death which had raised no concerns from either the ambulance or police
services.

In line with CQC requirements, I submitted a Notification 16 (Death of a Resident) to
CQC on 2"4 October 2018 before I went on leave.

Following my return on 16¢, October, (after I had been informed that the post mortem
identified choking for the reason of death), I was asked to provide a personal statement
to the Coroner’s office along with all documentation relating to Mrs Mekins and formal
statements from the care and nursing staff which I did.

I took the view, obviously mistaken in hindsight, that as CQC had been notified
immediately and the Coroner was now carrying outa full investigation before the
Inquest, that it would be inappropriate for me to conduct a separate investigation.

However, it became apparent at the end of November that further investigation was
required and I submitted a Safeguarding Alert to Hartlepool Social Services on
3.12.2018.

I attended a Lessons Learned Meeting on 8", January 2019, at which both Hartlepool’s
Safeguarding and Commissioning Teams, a representative from the CCG (NHS) and the
Police were present.

It became apparent at this meeting that the family had been upset that they had initially
been told by the Nurse on duty at the time that Mrs Mekins had died ofa heart attack -
which was obviously incorrect.

The CCG suggested we draft a Protocol for staff to follow after a death (sudden or
otherwise) and we implemented this immediately following the Lessons Learned
Meeting. The CCG also suggested that we draft a form where the home could document
any concerns identified as risks associated with a resident’s decisions and advice to
mitigate those risks.

Again, we accepted this advice and produced a Health Concerns or Advice Sheet to
identify to residents and/or families the possible consequences of their actions where
concerns have been identified by care staff and unwise decisions may have been taken.

It was also apparent from my e-mails with your office that the Choking Risk Assessment
used by Rossmere was not easily understood. We therefore liaised in depth with the

3

SALT team and, in consultation with them, produced a more user-friendly Choking Risk
Assessment which is more easily understood by professionals and staff alike.

I can forward you copies of all these new documents if you wish and hope that the
actions we have taken reassure you that our residents are not at risk of serious injury or
death and that we have accepted and acted upon all advice from your office and from
the Lessons Learned Meetings.

| attended a further Lessons Learned Meeting on 5th, March where the Safeguarding
Investigation was closed with no further action required.

Please let me know if you require copies of any documents referred to in this response
or any other information.

Yours faithfully,

Registered Manager