Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0212, written 26 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 | 26 Jun 2019 |
|---|---|
| Reference | 2019-0212 |
| Deceased | Charles Knapp |
| Coroner | Anna Crawford |
| Coroner area | Surrey |
| Category | Community health care |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
IN THE SURREY CORONER’S COURT IN THE MATTER OF: __________________________________________________________ The Inquest Touching the Death of Mr Charles Knapp A Regulation 28 Report – Action to Prevent Future Deaths __________________________________________________________ 1 THIS REPORT IS BEING SENT TO: , Director and Ray , Manager Angel Solutions (UK) Limited Ground Floor Challenge House, 616 Mitcham Road, Croydon, UK, CR0 3AA United Kingdom 2 CORONER Miss Anna Crawford, HM Assistant Coroner for Surrey 3 CORONER’S LEGAL POWERS I make this report under paragraph 7(1) of Schedule 5 to The Coroners and Justice Act 2009. 4 INQUEST The inquest into the death of Mr Charles Knapp was opened on 14 March 2018. It was resumed on 17 June 2019 and the conclusion was handed down on 18 June 2019. The medical cause of Mr Knapp’s death was: 1a. Aspiration pneumonia 1b. Paraplegia 1c. Spinal Injury sustained in 2008 2. Pressure Sores 1 The inquest concluded with a narrative conclusion, which is set out below. 5 CIRCUMSTANCES OF THE DEATH In 2008 Mr Knapp suffered a spinal cord injury, the cause of which is unknown, which left him paraplegic. Mr Knapp was at high risk of developing pressure sores due to his immobility and incontinence and required assistance with all aspects of daily care. He lived alone at his home address and was in receipt of a package of care which was funded by Surrey County Council and provided by Angel Solutions UK Limited. On 1 December 2017 Mr Knapp was found to have two necrotic pressure sores, which had developed primarily as a result of sitting in his wheelchair and contributed to by an omission on the part of his carers to maintain his personal hygiene and to regularly reposition him. They also omitted to seek medical attention for the pressure sores. On 12 December 2017 Mr Knapp was admitted to East Surrey Hospital as a place of safety due to concerns about the care he was receiving at home. On 24 February 2018, whilst at the hospital, he developed Aspiration Pneumonia to which he succumbed later that day. The pressure sores caused him pain and led to him eating and drinking in a non-upright position, which contributed to the development of the Aspiration Pneumonia. 2 6 CORONER’S CONCERNS The Coroner’s concerns are as follows: (i) Angel Solutions (UK) Ltd omitted to maintain Mr Knapp’s personal hygiene or regularly reposition him, and thereafter omitted to seek medical attention for the pressure sores. These omissions contributed to the development of the pressure sores and to Mr Knapp’s death. (ii) Angel Solutions (UK) Ltd did not always provide Mr Knapp with two carers, despite his care plan requiring two carers to be present in order to move him and otherwise effectively care for him. (iii) Angel Solutions (UK) Ltd failed to provide the court with a full set of Mr Knapp’s records, and as such the court did not have the opportunity to review the records for the key period prior to the development of the pressure sores. (iv) Angel Solutions (UK) Ltd failed to supply the court with the full name and contact details of the main carer who was responsible for Mr Knapp’s care and as such the court did not have the benefit of hearing from her. Further, her surname had been redacted from the records which were left at Mr Knapp’s house. The MATTER OF CONCERN is: The Coroner understands that although Angel Solutions (UK) has now been rated as inadequate following an inspection carried out by the Care Quality Commission in March 2019, it continues to provide care to approximately 8 individuals. The Coroner is concerned that there is a risk that the company will provide inadequate care to those individuals and keep inadequate patient records in respect of them, which gives rise to the risk of future deaths. 7 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that the people listed in paragraph one above have the power to take such action. 3 8 YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed. 9 COPIES I have sent a copy of this report to the following: 1. Chief Coroner 2. Mr Knapp’s family 3. First Community Health and Care 4. Surrey County Council 5. Care Quality Commission 10 Signed: Anna Crawford H.M Assistant Coroner for Surrey Dated this 26th day of June 2019 4
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