Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0383, written 15 Nov 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Nov 2019 |
|---|---|
| Reference | 2019-0383 |
| Deceased | Averil Skoric |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Secretary of State for Health CORONER | am Alison Mutch, Senior Coroner, for the Coroner Area of Greater Manchester South 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 5" March 2018 | commenced an investigation into the death of Averil Skoric. The investigation concluded on the 2" October 2019 and the conclusion was one of Narrative: Died from complications of positional asphyxia contributed to by positioning and her underfying frailty. The medical cause of death was: 1a) Bronchopneumonia with Positional Asphyxia on a background of Frailty and Vascular Dementia; II) Chronic Obstructive Pulmonary Disease CIRCUMSTANCES OF THE DEATH Averil Skoric had vascular dementia and had become increasingly frail in the months prior to her death. As a result her mobility was very limited. On 3" March 2018 she was put to bed on her back in the care home where she was residing. On 4" March 2018 she was found on her front. On the balance of probabilities she had rolled onto her front having been left on her side in a way that made it easy for her to move into an unsafe sleeping position. She had died from positional asphyxia as a result. 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. — _ inquest was told that: Mrs Skoric was a vulnerable resident who lacked capacity. Once she was on her front she was unable to move herself back into a safe sleeping position. She had to be regularly moved during the course of a night to check to see if she needed changing. There was no clear guidance available to care home staff locally or nationally about safe sleeping positioning of vulnerable adults in their care to avoid this cadre of adults being placed in a position which created an increased risk of unsafe sleeping. 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 10" January 2020. 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely )» | on behalf of the family 2) Clyde & Co Solicitors on behalf of Riverside Care Home 3) Care Quality Commission, 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. Alison Mutch OBE HM Senior Coroner 15.11.2019
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.
ae From Caroline Dinenage MP D ep artm ent Minister of State for Care of Health & 39 Victoria Street Social Care Swit OEU 020 7210 4850 Your Ref: 9752/MG Our Ref: PFD-1197061 a Ms Alison Mutch OBE 22 JAN 2020 HM Senior Coroner, Manchester South HM Coroner's Court HM CORONER 1 Mount Tabor Street MANCHESTER SOUTH Stockport SK1 3AG Z1 IY anuary 2020 Deor Huson, Thank you for your correspondence of 15 November 2019 to EE about the death of Mrs Averil Skoric. I am replying as Minister with responsibility for adult social care. Firstly, I would like to extend my deepest sympathies to Mrs Skoric’s family and loved ones. We must do all we can to improve the safety and quality of services and I am grateful to you for bringing these matters to my attention. In considering your concerns, Departmental officials have contacted the Care Quality Commission (CQC) and the National Institute for Health and Care Excellence (NICE). Although there is no specific guidance concerning safe sleeping positions of residents who lack capacity or are at risk from the consequences of unsafe sleeping, the CQC expects a provider, caring for someone with the type of needs that Mrs Skoric had, to meet the fundamental standards as outlined in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.' This includes: ' https://www.legislation.gov.uk/ukdsi/2014/9780111117613/contents e Person-centred care: A provider must do everything reasonably practicable to make sure that people who use the service receive person-centred care and treatment that is appropriate and meets their needs; e Safe care and treatment: A provider must do everything reasonably practicable to ensure that care is provided in a safe way; and, e Staffing: A provider must deploy enough suitably qualified, competent and experienced staff. The CQC also expects that providers would be able to demonstrate they are meeting the relevant Key Lines of Enquiry of the Adult Social Care Assessment Framework’. As part of the Key Line of Enquiry covering the assessment of a person’s needs and delivering care in line with current legislation, standards and evidence-based guidance, the CQC expects that a person’s needs are fully assessed, including risks to their health, safety and wellbeing. Inspectors expect a provider to assess the level of risk where someone is unable to reposition themselves in bed, their frailty, and the level of support or supervision they require to keep them safe. Other Key Lines of Enquiry include questions on sufficient numbers of adequately trained staff and how people are supported to live healthier lives, have access to healthcare services and receive ongoing healthcare support. The regulations and assessment framework are sufficiently broad to ensure they encompass the range of providers that the CQC regulates, the range of services they provide and the spectrum of needs experienced by the people receiving services. The CQC expects providers to follow and meet the relevant detailed or best practice guidance that is applicable in a particular care setting or to meet a specific need. Staff who are involved in providing care and support should be appropriately trained and should have the benefit of access to professional support from social workers, occupational therapists and other relevant experts as appropriate. Professionals can support the identification of any underlying conditions or ensure that complex needs are identified early and that people are signposted appropriately. In addition, providers are expected to follow the NICE guidance, ‘Dementia: assessment, management and support for people living with dementia and their carers’ (NG97*), published in June 2018. This provides guidance to staff caring for * htips://www.cgc.org,uk/sites/default/files/20180630_asc-registration-assessment-framework-with-sources-of- evidence v009.pdf > hutps:// www, nice.org.uk/guidance/ng97 people living with dementia who have sleep problems and advises staff to consider a personalised multi-component sleep management approach that includes sleep hygiene education, exposure to daylight, exercise and personalised activities. Finally, my officials have brought your concern to the attention of the Social Care Institute for Excellence (SCIE) which provides knowledge resources, training and support to the social care sector to promote the provision of good practice. I hope this reply is helpful. orn CAROLINE DINENAGE
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