Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0246, written 23 Jul 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Jul 2019 |
|---|---|
| Reference | 2019-0246 |
| Deceased | Barbara Humphreys |
| Coroner | Ian Boyes |
| Coroner area | South Wales Central |
| Category | Care Home Health related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Care Inn Ltd and Crosfield House Ltd
2. Care Inspectorate Wales
3. NHS Wales
1
CORONER
I am Ian Boyes, Assistant Coroner, for the coroner area of South Wales Central
2
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.
3
INVESTIGATION and INQUEST
4
I concluded an inquest on 11th July 2019. The medical cause of death was 1a
Complications of Ischaemic Heart Disease, 1b Femoral Artery Thrombosis, 1c
Peripheral Vascular Disease, 2 Immobility. The Coronial Conclusion was natural causes.
CIRCUMSTANCES OF THE DEATH
Barbara Humphreys was admitted into Crosfield house on 29 July 2018. This followed
concerns regarding her care at her home in London. The mission to Crosfield house was
initially in an emergency respite care basis but this developed into permanent care. On 3
August 2018 it was decided by a registered nurse employed by the company that bed
rails were required for this is Humphreys. No risk assessment regarding the safe use of
bed rails was completed by the care home.
On 2 September 2018 Mrs Humphreys was found to be on the edge of her bed with her
back pressed against the bed rail which caused a red mark. On 6 September 2018 she
was found at 1:15 PM with her legs between the bedrail mattress no bumpers in situ and
a red mark was noticed on her right shin. On 7 September at 11 o’clock it was noted that
she had got her legs trapped between her bed rails. On 28 October 2018 she was
observed to have her right lower leg trapped between the bed rails in bed while
sleeping. On 16 November 2018 her right foot was again trapped between the mattress
and bed rail and the lower part of the calf had gone a blue/purple colour. The foot was
firmly trapped and took two carers to free the foot. Request was made for her to see the
general practitioner however the general practitioner on that occasion decided not to see
Mrs Humphreys. On 17 November 2018 Mrs Humphreys again had her foot between the
bed rails and mattress which cause slight mottling to foot. Later that day Mrs Humphreys
was taken to Bronglais hospital in Aberystwyth whereupon she underwent an
amputation of the lower right leg from above knee. Sadly Mrs Humphries passed away
in hospital on 28 November 2018. Despite the occurrences with regards to the bed rails
the pathologist was of the view that the medical cause of death was, despite initial
appearances, as a result of a thrombosis above the levels of constriction/entrapment of
her leg and as such was natural causes. In the care home Mrs Humphreys had been
1
made subject to a DNAR order of which the family were unaware and had been
described by the GP as being for palliative care only when in fact she was not.
5
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. –
The evidence in the case revealed a number of issues relevant to the use of bed rails
and training of staff. I note that Crosfield house Ltd have been written to by the health
and safety executive in relation to matters which were within the remit of the health and
safety executive. I understand that a recent inspection by Care Inspectorate Wales has
shown dramatic improvement. Nonetheless the concerns are such that I feel it
appropriate to bring certain matters to the attention of the wider view.
1. The first issue is directed to Crosfield house Ltd and Care Inn limited and Care
Inspectorate Wales. It relates to the use of mattresses which are either not designed for
use on particular beds or when used on particular beds are not constructed or designed
to maintain a level when a patient is placed in the centre of said mattress. Upon placing
of a patient in the centre of said mattress certain mattresses can fold at the edge and
otherwise become displaced such that a patient’s limbs will not be maintained within the
mattress area. The correct mattress for the correct bed is considered de minimus in
terms of a standard
2. The second issue is also directed to Crosfield house Ltd and Care Inn limited and
requires adequate training to be provided to all employees in the homes operated by
your respective companies. The training should include the selection, fitting,
management and review of bed rails and accompanying bedding arrangements
3. The third issue is also directed to Crosfield house Ltd and Care Inn limited. The staff
and care homes in general under your control should complete a full and frank risk
assessment in relation to any and all issues with regards to bed rails. This should be
conducted with the input and knowledge of a patient’s family members, if they so wish
and the risk assessment should be reviewed regularly.
4. The fourth issue is directed to Crosfield house Ltd and Care Inn limited. The company
should produce and implement a full bed rail policy which is either group wide or
relevant specifically to Crosfield house Ltd. This should detail how the company intends
to ensure their employees are following the letter and spirit of the regulations.
5. The fifth issue is directed to Crosfield house Ltd and Care Inn limited which is there
was evidence that the completion of care plans and best interests assessments was
required to be fitted round other duties and as such may not be completed in a timely
fashion. The group and the care home shall consider whether assigning a set or allotted
period of time for a RGN to complete the care plan and assessment in the working day
would help ensure that the care plan is most accurate and appropriately detailed.
6. The sixth issue is directed to care Inspectorate Wales and National Health Service
Wales. They shall consider and if so appropriate, draft and implement a policy which
requires a care home or care provider to inform the family and next of kin of events in
which are medically trained professional has attended to or seen the patient particularly
in cases where there is no or varying capacity.
7. The seventh issue is directed to National Health Service Wales who should consider
and if so appropriate draft and implement a policy to ensure that families of those
assigned to palliative care and/or made subject to DNAR orders are provided sufficient
information about how that decision has been made, that they as a family have been
fully involved in the decision-making process and upon what information it has been
made such as the limits of patient confidentiality may allow in the circumstances.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and your
organisation have the power to take such action.
2
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 17th September 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to family who may find it useful or of interest.
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.
9
23rd July 2019 SIGNED: (electronic signature)
I D Boyes- Assistant Coroner
3
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.
Bwrdd lechyd
Addysgu Powys
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E-bost / Email:
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Powys Teaching
Carol Shillabeer, ¥ Prif Weithredwr / Health Board
Chief Executive
Ffon / Phone:
E-bost / Email;
7 Nie
2 September 2019
Our Ref: WM/RM/147
Your Ref: 15662
Mr | Boyes
HM Assistant Coroner
Coroner's Office
The Old Courthouse
Courthouse Street
Pontypridd
CF371 JW
Dear Mr Boyes
Regulation 28 Report reference Barbara Humphreys (deceased)
| write in response to receipt of the Regulation 28 report in respect of the above
named.
The health board became aware of this sad incident through our care home
governance monitoring processes. On behalf of the health board | extend
sincere condolences to Mrs Humphries’ family.
In response to the matters of concern, | have detailed below the actions taken
by the health board to put improvements in place to improve the care and
treatment provided and to ensure lessons are learnt and shared. We are further
sighted on the actions led through the Adult Protection General Protection Plan
overseen by Powys County Council as part of our care home governance
arrangements, which we take account of through our commissioning assurance
framework. The latter seeks to provide assurance on the quality, safety and
experience of care and treatment provided for residents who access the care
homes.
Assurance has been provided to the health board on the actions that have taken
place in response to the Adult Protection General Protection Plan which
addresses matters 1-5 of the Regulation 28 report. The health board has also
received confirmation that the MHRA: Safe use of bed rails (December 2013)
guidance was circulated to all Care Home Providers in February 2019 for their
Pencadlys Headquarters
TY Glasbury, Ysbyty Bronilys, CYFLOGWELYSTYRIOL Glasbury House, Bronllys Hospital
Aberhonddu, Powys LD3 OLU MINDFUL EMPLOYER Brecon, Powys LD3 OLU
Ffon: 01874 711661 Tel: 01874 711661
Rydym yn croesawu gohebiaeth Gymraeg Fan . st My, We welcome correspondence in Welsh
Bwrdd lechyd Addysgu Powys yw enw gweithredd Bwrdd lechyd Lleol 3 K v Ai 3 VV (s Powys Teaching Health Board is the operational name of
&
Addysgu Powys % egy Powys Teaching Local Health Board
a
i)
reference as part of the wider sharing of lessons. Through our care home
governance framework, the health board will continue to monitor the standards
of care and treatment provided to Powys residents. A planned date for a joint
monitoring visit with Powys County Council was in place but was subsequently
postponed whilst the regular visits from the Health and Safety Executive and
Care Inspectorate Wales took place. Importantly, a new date is currently being
agreed for the visit which will be unannounced. The team that undertakes
review visits has also been strengthened with a new addition to the team
representing pharmacy and medicines management.
With reference to point 6 and 7 of your report ae Medical Director,
Powys Teaching Health Board has reviewed the Regulation 28 report and
progressed the following actions:
has taken account of the General Practitioner's (GP) standard of
behaviour, professional practice and record keeping standards. The latter is
particularly important where impairment of capacity is present, as in this case,
and the need to ensure the family/next of kin are informed of both a doctor's
attendance and their management plans. He has highlighted the importance of
keeping accurate records as a doctor, a requirement within the General Medical
Council's (GMC) ‘Good Medical Practice’ httos://www.gmc-uk.org/ethical-
quidance/ethical-quidance-for-doctors/good-medical-practice (paras 19-21).
In reference to ‘do not attempt cardiopulmonary resuscitation (DNACPR)'
orders, Mr Parry has highlighted the considerations here in relation to the
doctor's role. The doctor needs to be aware (if they are not already) of the GMC
guidance https://www.gmc-uk.org/ethical-quidance/ethical-quidance-for-
doctors/treatment-and-care-towards-the-end-of-life on both lack of mental
capacity (paras 15 and 16) and DNACPR (paras 129-136). Both sections
highlight the need for discussion with carers/family members and related care
givers and the need to be clear on the process for and justification of, any
decisions that are made about the individual patient. Although it is suggested a
policy is constructed around these, it is in fact the case that this already exists
insofar as it would relate to doctors in this scenario, and this is within the
referenced GMC guidance above.
{can confirm Mr Parry is writing to the General Practitioner concerned with the
intention of outlining the following:
1. The importance of clarity and transparency in their interactions with
Crossfield and other institutions for which they provide medical services.
This transparency would include attending within a reasonable time
scale when requested and making their presence known to the facility
when they do attend.
2. The GP’s responsibilities when reviewing patients as requested to do so
and making properly documented contemporaneous written (or
electronic as appropriate) records of their attendance, findings and
management plan.
3. Ensure that discussions are undertaken with the patient/ family/ care
givers that not only acknowledge the patient/ family/ care givers views
but also make plain the management plans being proposed. These
discussions, and their agreed outcomes, must be documented in the
patient record.
4. That where issues of DNACPR appear to arise then discussions with the
patient (where capacity exists), family and care givers as to the
appropriateness of this are undertaken, agreed and documented in the
patient record.
| ss further confirmed his intention to make the GP aware of the
relevant GMC guidance referenced above and will request that this case is
discussed as an untoward event within the doctor's annual appraisal if it has
not been already. Additionally, it is important that the doctor reflects adequately
on the case, the guidance and the outcomes for them as a result.
| can further confirm with regards point 7, all residents without capacity should
have Deprivation of Liberty Safeguards (DOLs) in place for use of bed rails. In
order to complete the DOLs a Best Interest decision is completed. This will be
reviewed and monitored as part of the planned announced joint monitoring visit
within the care home governance framework.
| hope this response provides you with assurance that we have addressed the
actions cited in the said Regulation 28 report.
Yours sincerely ALULQh
Carol Shillabeer
Chief Executive
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