Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0334, written 8 Oct 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Oct 2019 |
|---|---|
| Reference | 2019-0334 |
| Deceased | Dylan Henty |
| Coroner | Andrew Cox |
| Coroner area | Cornwall and the Isles of Scilly |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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.
Information Classification: CONTROLLED REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) Dylan Jay Henty, deceased REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: a, lUlU CY Owner and Registered Manager of Pentree Lodge Home, 63-65 Pentire Avenue, Newquay CORONER | am Andrew Cox, Acting Senior Coroner for the coroner area of Cornwall and the Isles of Scilly. 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 13 March 2018, an inquest was opened into the death of Dylan Jay Henty who died on 21 February 2018. The inquest culminated in a final hearing on 19 — 20 September 2019 with an Open Conclusion being recorded. The cause of death identified at post-mortem was: 1A) multiple injuries CIRCUMSTANCES OF THE DEATH Dylan had a complex past medical history that included schizophrenia (for which he was in receipt of prescription medication) and a cerebral tumour that had previously been debulked. He suffered with difficulties in communication. There had been some history of non-compliance with medication which included verbal aggression towards staff. On two occasions, modest amounts of prescribed medication had been found in his room. He was known to suffer from seizures and in December 2017 had suffered a seizure in the bath while unsupervised. There had been at least two previous episodes of absconding from the home in October 2017 and February 2018. There was no history of previous overdoses or of attempts to take his own life. On 17/2/18, he appeared in good humour. He attended a party for another resident and was seen to dance. Later, he declined his prescribed medication. Subsequently, he was found to be missing from his room and a report was made to police. On 21/2/18, Dylan’s body washed up at the south end of Fistral beach. There is no evidence to explain the fall from height he appears to have suffered or how he came to end up in the sea. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to Information Classification: CONTROLLED 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. i. While it appears to have had no bearing on the circumstances of Dylan’s death, | was concerned to hear evidence of Dylan suffering a seizure in a bath while unsupervised. Similar episodes elsewhere in the country have resulted in criminal prosecutions. It is not clear to me whether reports were made to the CQC, GP and/or care coordinator. You may wish to reflect on the need for clear guidance and training to all staff on the arrangements for those residents with a known risk of seizure to take baths (as opposed to showers) where there is an obvious risk of drowning should a seizure occur. Similarly, those in management positions must be clear about the circumstances in which formal reports should be submitted to relevant bodies and you may feel there is a need to ensure these standards are rigorously checked and met. ii. | Dylan’s GP was unaware of previous incidents of hoarding. He felt this was something that should have been brought to his attention. You may wish to reflect on the need for clear guidance and training to all staff in such matters. Similarly, you may wish to reflect on the need for those in management positions to ensure rigorous compliance with the relevant standards. iii. Linked to the issue of hoarding is the question of how to ensure a resident is compliant with taking medication prescribed to him. It was accepted in evidence that, given the discovery of the medication in Dylan’s room, the system in place must have failed. It was recognised in court that there are limits to enforcing residents to take medication. Nevertheless, there needs to be a robust system in place and where there is doubt about a resident’s compliance, notification should be made to the relevant professionals iv. There appeared to have been inconsistency in the reporting of incidents of absconding. You may wish to reflect on the need, in similar circumstances, for reports to be made to the GP, care coordinator and CQC. Further, you may wish to consider at what point there is a need for such matters to be considered at MDT level, for example, to consider whether current residential arrangements continue to be appropriate. v. Linked to the above are the arrangements put in place to monitor residents where there have been previous incidents of absconding. There needs to be a clear recognition of what is realistic particularly when set against the desire to ensure the Lodge remains the resident’s home. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you [AND/OR your organisation] 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 20/11/2019. I, the coroner, may extend the period. Information Classification: CONTROLLED 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: the family and CPFT. | 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. [DATE] [SIGNED BY/GSORONER] 08/10/2019
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.
Pentree Lodge Care Home 63/65 Pentire Avenue, Newquay, Cornwall, TR7 1PD Tel: 01637 878437 Pentree Lodge Email: enquiries @ pentreelodge.co.uk Web: www.pentreelodge.co.uk ewwwssse = =CARE HOME LIMITED === 12" November 2019 Dear Mr Cox It is with sadness under the circumstances that we correspond. | would like to take this opportunity to evidence the actions taken by Pentree Lodge following Dylan’s unfortunate death. The actions are as follows: 1. Any resident that is known/diagnoised with seizures is to be encouraged to be assisted/escorted in the bathroom, in compliance with the relevant acts, dignity and consent from the resident. A shower is encouraged/advised over a bath and the relevant measures/ training to be put in place. Care Plans and Risk assessments to be done with the support and advice of the specialist Epilepsy Nurse. All relevent physical illnesses where an ambulance/out of hours doctor are called, accidents or hospital admissions are reported to the relevant bodies ie. Care co-ordinator. The GP has access to this information via R.I.O. A report is also sent to the GP from the relevant bodies. 2. Since the inquest management of the home have reviewed all residents physical health. Management have picked up that another resident who has a history of seizures, she hasn't had a seizure since being in the care home for over 5 years but has not been reviewed by any health professional for at least 10 years regarding her history of seizures. This is now being reviewed by When confirmation of this is sort the home will review its Risk Assessments and Care Plans and put in place the relevant measures surrounding bathing and showering, training on this specialist area will be undertaken by all staff. 3. The actions taken regardng the hoarding incident are as follows; The homes medication procedure was reviewed, all staff to attend rigorous face to face medication training on the 10" December 2019. All residents are to come to the office/medication room individually. Residents are given One to One time whilst medication is administered behind a closed door, allowing staff time to check medication is taken following the relevant standards and legislations. Room checks have been reviewed it was felt that there was little improvement to be made, other than if medication is found in a room then room checks are done immediately after medication times. This would be reviewed regularly, this has also been added to the homes Medication Policy. These changes are to be made within the home in the forth coming weeks following relevant guidelines and legislation. 4. The home also reviewed the wording used when undertaking care notes, such as hoarding. It could be argued in opinion whether two tablets found could be deemed hoarding, also if not taking three tablets is deemed medically as non compliant. Of a PE a ey Director: Lesley Richardson R.M.N Registered Company No. 8027154 course this should be documented and the relevant bodies made aware but mindful of the wording used when undertaking care notes. In such incidents a request would be made by the home for the relevant health professionals to carry out relevant assessments such as Capacity etc where appropriate. 5. The home recognised that there were communication errors between MDT and can only apologise. Firstly we now liaise with the GP and mental health team regarding relevant issues we face. Notifiying all concerned via telephone or email and documenting where appropriate. All incidents of absconding are reported to the relevant bodies ranging from the Care Team to the Police. Measures are then taken to prevent further incidents occuring, such as observations following the relevant laws and legislations such as DOL’s , Capacity Assesssment, Mental Health Assessment that need to take place before the home has the power to prevent someone leaving the building as the home is an open facility. Lawfully this documentation needs to be put in place and legislation followed. 6. Dependent on the level and frequency of abscontion the intention and the risk. The appropriate placement of the home would be assessed. The MDT would immediately be informed in the event of any abscontion, if there are relevent teams in place, if not a referral is made. Reviews and monitoring visits take place 6 weekly or more frequent if needed by the care home. The placement of the home is reviewed in these visits if needed and where appropriate. We as a home would like to offer our sincere condolences to the family and endevour to prevent where possible similar incidents occuring in the future. Lh Yours sincerely Director ————— a SS SS a a a EE Director: Lesley Richardson R.M.N Registered Company No. 8027154
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