John Doyle

Date of report	3 Jul 2019
Reference	2019-0226
Deceased	John Doyle
Coroner	Nadia Persaud
Coroner area	East London
Category	Hospital Death (Clinical Procedures and medical management) related deaths
Organisation named	North East London NHS Foundation Trust
Source	judiciary.uk record · original PDF
Responses published	1

The report

Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.

East London Coroners

MISS N PERSAUD
SENIOR CORONER

Walthamstow Coroner's Court, Queens Road Walthamstow, E17 8QP
Telephone 020 8496 5000 Email coroners@walthamforest.gov.uk

REF:9469

3 July 2019

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO: John Brouder, Chief Executive, North East London Foundation Trust,
Goodmayes Hospital, Barley Lane, Goodmayes, Ilford, Essex, |G3 8X!

=
CORONER

lam Miss N Persaud Senior Coroner for East London

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.

http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7

http://www. legislation.gov.uk/uksi/2013/1629/part/7/made

INVESTIGATION and INQUEST

On 21/01/2019 | commenced an investigation into the death of John Patrick Doyle. The investigation
concluded at the end of the inquest 25th June 2019. The conclusion of the inquest was a narrative
conclusion:

Mr Doyle died as a result of starvation ketoacidosis, following a likely fall in his home address. It is likely
that he was unable to get up or seek assistance, following the fall. He had suffered a similar fall and long-
lie, some months prior to his death. The need for a panic alarm was identified, but no alarm had been put
in place at the time of his death.

CIRCUMSTANCES OF THE DEATH

Mr Doyle was admitted to hospital in July 2018 having fallen at his home address. Following the fall, he
had laid undiscovered for 4 to 5 days. He was discharged from Hospital on the 10 September 2018. Prior
to his discharge, there was recognition of a need for a panic alarm. A panic alarm was requested, by the
occupational therapist with an urgency level of “high” on the 4 September 2018. There were initial
difficulties in reaching Mr Doyle, but a home visit to arrange the alarm took place on 18 September 2018.
A different type of alarm was recommended, because Mr Doyle did not have a landline. Advice was
provided to the occupational therapist on how to request this, on the 27 September 2018. The
occupation therapist did not lodge the request until 4 October 2018. Sadly, Mr Doyle was found
deceased by a district nurse on the 3 October 2018. It is likely that he had suffered a fall and was unable
to get back up or to seek assistance. He died from starvation ketoacidosis.

CORONER'S CONCERNS

During the course of the inquest the evidence revealed a matter 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 MATTER OF CONCERN is the evidence heard around the training provided to occupational therapists
in relation to the emergency equipment available from Telecare. It is requested that the training for
occupational therapists is reviewed to consider:
I. The emergency alarm equipment available
I. The order process required for such equipment, and
Wi. The compatibility between the alarm system and the telephone systems within the home
setting.

It was also noted that technology changes frequently and therefore it is requested that a form of
refresher training is also considered.

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, namely by 28"
August 2019. |, 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.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following interested Persons,
(sister of the deceased) and to the London Borough of Barking & Dagenham. | have also sent it to
Mr Matthew Cole (Director of Public Health) and to the CQC who may find it useful or of interest.

!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.

03/07/2019

Miss N Persaud Senior Coroner East London

Responses

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.

Response from North East London NHS Foundation Trust (PDF)

NeLeT WE

Best care by the best people NHS Foundation Trust

(Chief Executive Office
West Wing
CEME Centre
Marsh Way, Rainham
Essex
RM13 8GQ |

PRIVATE & CONFIDENTIAL
Ms Nadia Persaud

Senior Coroner
Walthamstow Coroners Court
Queens Road

Walthamstow

Lodnon E17 8QP
Tel: 0300 555 1298

Email: CEQOffice@neltt.nhs.uk |

29 August 2019 |

[Dear Ms Persaud, |
[Re: Response to the Regulation 28 Report
| refer to a Regulation 28 report dated 3% July 2019.

The Trust is committed to continuously review its service for the purposes of improving quality of care and
patient safety and | am grateful to you for bringing these issues to my attention.

The Trust has given and continues to give the most serious consideration to the concerns regarding the
care provided to Mr Doyle, which were highlighted in the Regulation 28 report.
Please find enclosed the Trust’s action plan to address the issues identified in the Regulation 28 report.

Yours sincerely, |

Interim Chief Executive

Encl: Trust Action Plan |

F352 disabili
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EMPLOYER

www.nelft.nhs.uk

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Sent: ,

To:

Cc:

Subject:

Importance: High

Dear all,
Please read the patient safety alert below, particularly for OT colleagues or any other clinicians in our services who

carry out pendant alarm assessments and referrals. This is related to a patient incident within our CHS inpatient
wards, however, it is applicable to all of our services where there are referrals for pendant alarms. We have an
action plan from the coroners inquest which we will be completing and also working with Laura Stuart Neil — AHP
Lead to look into the processes as a NELFT wide learning. We will be picking this up in my DBM next month to share
the learning from the case, but | feel it is important to raise awareness before then. Please can you discuss in your
team meetings and ensure that our OT colleagues have seen the alert. There will be another formal alert released

from QPS, however, please share within your teams in the meantime.

eee NELFT Wi
Patient NHS Foundation Tr

safety alert

2049-004
18.07.2019
ID's, AC's and all OT's ir community and acute

Risk of delay of installation of a pendant
alarm for patients in the community setting.

Introduction:

There have bean hwo recent patient safely Incidents concerning the prescribing and supplying
of the pendant alarm system for community residing patients.

Action required:
In order ta reduce any assedated risk the following urgent action is required:

Any occupational therapist responsible for requesting provision of a pendant alarm via thelr local
authority musl ensure that the alarm is ordered promplly following assessment and musl ensura to
specify clearly on the referral form the patient's axisting lelephone system,

The occupational therapist must check with ihe patient andior family member, prior to forwarding
the referal, whether they have a working land ina phone. If the salient doas not have a working
landline phone then the occupational therapist musi check If the patient has @ mobile phone
compatible with the pendant alarm system issued in that local authorityfecallly.

if neither landline ner mobile phone Is in place the occupational Iherapist shavid cansull the
patient and/or family to confirm urgent arrangements for a sultable landline or mobile phone to
enable the pendant sian request ta be made. If necessary the cccupational therapist must rafer
fo the local authorily for assistance with getting this up.

Please rafer to your local authority guidance on their process for issuing pendant alarms.

This will be monitored vis the Quality & Patient Safety team audit of the minutes of DBM's
meeting,

Sent: ugus :

To:

Ce:
Subject:

Hi Team OT

OT’s have a Telecare training on 27.08.2019 at 12:00 -12:30 in the Japonica Meeting room with | fe put
this in your diary and attend.

Thanks to , wi providing this

Kind Regards

Band 7 Physiotherapist

NELFT NHS Foundation Trust

Acute and Rehabilitation Directorate
Foxglove and Japonica Wards

King Georges Hospital

\Iford,

IG3 8YB.

Tel: 0300 555 1201 Ext. 58704

Working Pattern: Tuesday — Friday 08:00-16:00

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Best care by the best people NHS Foundation Trust

NELFT IRS — Occupational Therapy Meeting
Block 8 Meeting Room

Wednesday 18/9/2019, 3pm

AGENDA

itle of i Person . Time

Title of item presenting Time limit
1. | Apologies

2. | Minutes of the last meeting

3. | Matters arising
4. | IRS Equipment |
minutes

4.1 Review of previously clinically reasoned equipment
4.2 Plan for next equipment to be reviewed
4.3 Update on telecare process for BHR boroughs

5. | Training needs NELFT 20
pharmacy minutes
5.1 NELFT pharmacy presentation for medication aids team
6. | OT caseload 5
minutes

6.1 Delegation to Rehab Assistants

7. | AOB 5
minutes

8. | Date and time of next meeting
- _ First Wednesday of every month at 3pm

Best care by the best people

Title of item

NELFT

NHS Foundation Trust

NELFT IRS — Occupational Therapy Meeting

Block 8 Meeting Room

Wednesday 18/9/2019, 3pm

AGENDA

Person Time
presenting Time limit

E 1. | Apologies {
2. | Minutes of the last meeting
E 3. | Matters arising
4. | IRS Equipment 30
minutes
4.1 Review of previously clinically reasoned equipment
4.2 Plan for next equipment to be reviewed
4.3 Update on telecare process for BHR boroughs
5. | Training needs NELFT 20
pharmacy minutes
5.1 NELFT pharmacy presentation for medication aids team
6. | OT caseload 5
minutes
6.1 Delegation to Rehab Assistants
7. | AOB 5
minutes
8. | Date and time of next meeting
-__ First Wednesday of every month at 3pm

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Sent: H
To:
Cec:

Subject: RE: Pendant alarm working group

Many thanks! | will be in touch...

Director of Quality Improvement/ Director of Allied Health Professions & Psychological Therapies
NELFT NHS Foundation Trust

Email:
Please note | do not normally work on Fridays.

www.nelft.nhs.uk/quality-improvement, @laurajstuart, @netftqip, @NELFT_AHP
Member of the London Clinical Senate Council - www.londonsenate.nhs.uk

Contact for QI enquiries:
For other enquiries: Mar;

a NHS ee

* Quality moentber
NHS Foundation Trust improvement Sere,
Programme aqhesichotaieh,

Sent: 2
T
C

Subject: Pendant alarm working group

fim who are both occupational therapists within the Intensive Rehab Service are keen and interested
to be part of the working group around pendant alarms.

Please let me know if there is any other information you need. Pe: copied into this email as
well as im: is the service lead.

Many thanks

Intensive Rehabilitation Service
North East London Foundation Trust
Acute and Rehabilitation Directorate
Goodmayes Hospital

Block 8

Barley Lane

CO SE ee
ee

From:

Sent: 24 September 2019 15:45

To:

Subject: Response to Reg 28 Report - your ref 9469

Attachments: Regulation 28 Report Feedback August 2019.pdf, D83196 - Regulation 28 action
plan 27.08.19.pdf

Good afternoon

Regulation 28 Report — your reference 9469

Thank you for taking the time to speak with me. Further to our conversation, please find attached the letter and
action plan sent by NELFT in response to the Regulation 28 Report; | do apologise if this did not reach you when sent
originally. | would be very grateful if you could bring this to the attention of HM Coroner with our sincere apologies
for the delay.

| would be grateful if you could confirm safe receipt.

If you require anything further on this matter then please do let me know

Kind regards

Deputy Head of Corporate Affairs

NELFT
North East London NHS Foundation Trust
CEME Centre, West Wing, Marsh Way, Rainham,Essex, RM13 8GQ

www.nelft.nhs.uk

FT WE

NHS Foundation Trust
Best care by the best people

HEALTHY
WORKPLACE

ACRE RT
2018

MAYOR OF LONDON

This email and any attachments are or may be confidential and legally privileged and are sent solely for the
attention of the addressee(s). If you have received this email in error, please delete it from your system: its
use, disclosure or copying is unauthorised. Statements and opinions expressed in this email may not
represent those of NELFT. Any representations or commitments in this email are subject to contract.

NELFT NHS Foundation Trust

The report

Responses

Related reports

Other reports by Nadia Persaud

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Track North East London NHS Foundation Trust