Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0184, written 3 Jun 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Jun 2019 |
|---|---|
| Reference | 2019-0184 |
| Deceased | Kathleen Smith |
| Coroner | David Pojur |
| Coroner area | North Wales (East and Central) |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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Mr David Pojur Assistant Coroner North Wales (East and Central) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Coed Duon Care Home, Halkyn Road, Hollywell, Flintshire, CH8 7SJ CORONER | am David Pojur, Assistant Coroner for North Wales (East and Central) 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. INVESTIGATION and INQUEST On the 21 May 2018 this Court commenced an investigation into the death of Kathleen Smith (DOB 04.12.33 DOD 12.05.18). The investigation concluded at the end of the inquest before me on the 12 April 2019. The Conclusion of the inquest was delivered by way of a narrative stating: Kathleen Smith died at Coed Duon Nursing and Residential Home on 12 May 2018. She had advanced dementia and was at risk of choking. She needed a pureed diet. Staff had not received sufficient training and fed her unsuitable food. She began coughing and was aspirating. A nurse was called to her room and staff did not examine or assist Kathleen Smith. She aspirated on the food material and died thereafter. The Cause of Death is recorded as: 1(a). Aspiration of Food Material 1(b). Right Sided Early Pneumonia 2. Dementia and Astma Coroner's Office, County Hall, Wynnstay Road, Ruthin, LLIS 1YN Tel 01824 708047 | Fax 01824 708048 CIRCUMSTANCES OF THE DEATH Kathleen Smith required one to one care for food and fluids and entered the Home with a known risk of choking for which there was a risk assessment on her file. She was on a fluid thickened diet and pureed food diet. The part time carer who fed her breakfast had no suitable training to do so nor knowledge surrounding her food and fluid needs. The carer only had manual handling training. Inappropriate food was fed to Mrs Smith. She was coughing and help was summoned. There was poor communication between staff as to the nature of the emergency. Whilst a nurse and another senior member of staff attended, they did not assist Mrs Smith. Instead paper work was checked and telephone calls were made. 999 was not called. 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: = . Staff were not sufficiently trained in first aid or how to assist a resident who was at risk of choking. 2. Staff did not intervene to assist the resident for whom the internal emergency alarm had been sounded as help was needed. 3. Staff were not sufficiently trained in how to select and prepare correct foods and fluids for residents with special dietary needs and who had a documented risk of choking. 4. The above training remains incomplete approximately 11 months after the death of Mrs Smith. 5. Staff could not demonstrate they understood how to deliver safe care and treatment regarding food and fluids and manage the risk of choking. 6. There is no adequate management oversight to ensure staff are appropriately deployed to those residents at risk of choking and or who require one to one assistance with food and fluids. Coroner's Office, County Hall, Wynnstay Road, Ruthin, LLIS 1YN Tel 01824 708047 | Fax 01824 708048 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, 29 July 2019. |, the Coroner or the Senior 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, the Family of the Deceased and the Care Inspectorate Wales. | 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. Dated 3 June 2019 proner North Wales (East and Central) Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL1S 1YN Tel 01824 708047 | Fax 01824 708048
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.
Coed Duon Care Home Halkyn Road, Holywell, Flintshire CH8 7SJ 27% July 2019 Our Ref: CR/KS/0306 Mr John Gittins HM Senior Coroner for North Wales (East & Central) HM Corner’s Office County Hall Wynnstay Road Ruthin, Denbighshire LL15 1YN Dear Sir Re: - Report dated 03 June 2019, from Mr David Pojur, the assistant Coroner for North Wales (East and Central). Regarding the circumstances of the death of Mrs Kathleen Smith, Resident at Coed Duon Nursing Home. In line with our duty of care, | write in response to the above report. Could | at the outset, again extend my sincere condolences to Mrs Smiths Family from all the staff at Coed Duon. The death of any resident in our care is distressing for all those involved. Sadly however, they are sometimes what we must unavoidably witness. Nevertheless, notwithstanding this tragic case, | can assure you that our staff are responsible and caring, as was unanimously confirmed by the resident’s family’s in response to the questionnaires which we sent out in May this year as part of our quality assurance report for the CIW As you can imagine, the death of Mrs Smith has affected our staff deeply, especially as your report levels an element of blame against them. However, | must accept the conclusions of the report and have therefore taken steps to implement changes to mitigate against a repetition of this sad occurrence. Nevertheless, in defence of my staff, Mrs Smith had been at the home four weeks, during which time the staff had been regularly feeding her satisfactorily. On the day in question Mrs Smith's carer, who incidentally had several years’ experience who was feeding her. From your report there appears to be no evidence that the food which she had aspirated had not been prepared to a proper safe consistency. As must have been done satisfactorily with no adverse effects on so many occasions before. | would respectively suggest that the cause of Mrs Smith’s death was not due entirely to one single factor which can be leveled entirely at our door, but as your report concludes it was sadly a combination of things including the fact that she was in early stages of pneumonia, and was suffering from both dementia and asthma (Astma in the report). It was these three factors which combined to contribute to her death With regards to the specific points in the order you raised them: - ia. You expressed concerns in your report regarding our lack of adequate first aiders. Since then | have, despite difficulty obtaining vacant slots, several members of staff on first aid courses. This now allows us to have at least one qualified First Aider on duty. tb. All current staff have now been trained on basic awareness of Dysphagia. Also all new staff members have been booked on next available SALT (IDDS) training day which is on 6/08/19. We also now have 2 Dysphagia champions who have done the training for Dysphagia and who are now fully equipped to carry out to train all our staff. We have now set up a Diets and fluids consistency file for each resident, which have been graded by the exterior health professionals, this file is held in the kitchen and all the kitchen staff have been trained to be aware of its content. If any changes occur hey are given a copy of these changes and all staff now sign to say they acknowledge if there are any changes to their diets. 2. On the day in question, | must once again stress that two members of staff answered the emergency nurse call bell, one was the duty RGN and the other a senior carer, they did intervene and carer remained with her until she passed away, there was no sign she was in distress. 3. As part of their induction training all new staff members are taught how to deliver safe care in residents with a choking risk. We have also made it very clear to new staff that they are NOT allowed to assist residents at risk of choking until this training has been done. 4, We have an RGN on duty 24 hours a day, 7 days a week, also please refer to point 3. §. There is a trained member of staff on duty in the dining room during mealtimes to oversee the appropriately trained staff in Dysphagia to assist the residents at risk of choking. Also staff now write on diet & fluid charts what daily meals are served and they are clearer on what they have eaten, for example. puree mashed potatoes, puree, instead of Mash, Veg chicken 6. There is always an RGN in the dining room during mealtimes. Il can assure you | take my responsibilities extremely seriously and lessons have been learned, | will endeavour to uphold the highest of standards. | hope | have covered all the points which you had raised in your report, however, | welcome any constructive thought you may have in the light of these recent events. Yours faithfully — Proprietor
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