Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0320, written 18 Apr 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Apr 2019 |
|---|---|
| Reference | 2019-0320 |
| Deceased | Margaret Melia |
| Coroner | Zafar Siddique |
| Coroner area | Black Country |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive, HC-One, Southgate House, Archer Street, Darlington, DL3 6AH c/o Dovetail Court Care Home 2. Managing Director, Lakeview Care Home 3. Care Quality Commission are copied in for their reference only. 1 CORONER I am Zafar Siddique, Senior Coroner, for the coroner area of the Black Country. 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 On the 16 November 2018, I commenced an investigation into the death of Mrs Margaret Melia. The investigation concluded at the end of the inquest on 1 April 2019. The conclusion of the inquest was a short form conclusion of natural causes. The cause of death was: 1a Advanced Dementia b c II Old Age, Malnourished, Ischaemic Heart Disease 4 CIRCUMSTANCES OF THE DEATH i) Mrs Melia was admitted to Dovetail Court Care Home on the 9 October 2018 from Lakeview Care Home. She had a medical history including arthritis, Alzheimer’s, chronic obstructive pulmonary disease and required substantial care for her daily living activities. ii) As part of the pre-assessment, on the 29 September 2018, Mrs Melia was assessed by a manager from Dovedale Court. The nurse on duty (Lakeview Care Home) advised the assessor that she would be requesting the GP to visit her in 2 days (01.10.18) to prescribe subcutaneous fluids due to Mrs Melia’s oral intake was poor and it would be required if her fluid intake dropped below 500ml daily. iii) The relevant equipment required to administer subcutaneous fluids wasn’t available at Dovetail Care Home and no subcutaneous fluids were given. iv) Mrs Melia’s condition started to decline rapidly from around the 22 October 1 [IL1: PROTECT] and her food and fluid intake dropped. v) She was admitted to Sandwell Hospital and treated for dehydration and a lower respiratory tract infection with antibiotics. Sadly, her condition continued to decline and she was placed on end of life palliative care. She passed away on the 7 November 2018. 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. – 1. Evidence emerged during the inquest that there was an inadequate discharge and pre-assessment process between Lakeview Care Home and Dovetail Care Home over the requirement of subcutaneous fluids. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 1. Both Care Homes may wish to consider urgently reviewing the protocols in place during discharge and pre-assessment of patients. In particular, the requirement of any medication should be set out clearly to avoid any misunderstanding that could result in harm to a patient. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 13 June 2019. I, 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 the Chief Coroner and to the following Interested Persons; Family. 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 18 April 2019 Mr Zafar Siddique Senior Coroner 2 [IL1: PROTECT] Black Country Area 3 [IL1: PROTECT]
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.
Mr Zafar Siddique Senior Coroner Coroner’s Court Jack Judge House Halesowen Street Oldbury, B69 2AJ 13 June 2019 Dear Mr Siddique, I write to inform you of the actions taken at HC-One in response to your Regulation 28 report to prevent future deaths, following your investigation into the death of Mrs Melia. In response to the matters of concern highlighted, we took the following actions: We reviewed our policies and practices as an organisation in relation to our pre-admission and admission processes. We reviewed the current Admission process checklist. The action we have taken as a result: On reviewing our practices, we identified that if a delay occurred between the pre-admission assessment conducted, there needed to be clearer guidance set out for colleagues within our Admission, Transfer and Discharge Procedure (Appendix 1). We have now included practice that in the eventuality the pre-assessment was completed more than five days prior to admission to the home, further information should be sought from the hospital ward/care home/social worker as soon as possible. This will include the update of any medication changes or outcome of any recent healthcare professional reviews of the person during this period, to avoid any misunderstanding that could result in harm. The changes to practice have been cascaded across the organisation via our Homes’ Bulletin, which is sent to our homes. Our Admission process checklist (Appendix 2), which is available within all our homes to ensure all aspects of the organisation’s pre-admission and admission processes are completed, has been updated to reflect this improvement in practice. HC-One T 01325 351100 F 01325 351144 Correspondence & Registered Office: Southgate House, Archer Street, Darlington, County Durham, DL3 6AH Registered in England and Wales: HC-One Limited, registration no. 07712656; Meridian Healthcare Limited, registration no. 01952719; HC-One Beamish Limited, registration no. 05217764; HC-One Oval Limited, registration no. 10257888; RV Care Homes Limited, registration no. 07417290. I do hope this information is helpful and offers you the reassurance that we, at HC-One, have taken the issues raised seriously and have taken appropriate action with the intention of improving the care and safety of our Residents. Yours sincerely Head of Quality and Regulation Page 2 of 2
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