Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0400, written 27 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 | 27 Nov 2019 |
|---|---|
| Reference | 2019-0400 |
| Deceased | Andrew Hogg |
| Coroner | Christopher Briggs |
| Coroner area | Manchester South |
| 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Managing Director, Borough Care Ltd, 9 Acorn Business Park, Heaton Lane, Stockport SK4 1AS CORONER lam Christopher Briggs, Assistant Coroner for 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. 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 16" May 2019 an inquest was opened into the death of Andrew Richard Hogg, who died at the Stepping Hill Hospital on 6" May 2019 aged 66 years. The investigation concluded at the end of the inquest which | heard on 22" October 2019. At the end of the inquest | recorded that Andrew Hogg died as a result of an accident, namely a fall he had on 3 May 2019 while at the Meadway Court Care Home, Meadway, Bramhall, Stockport SK7 1JZ as a result of which he suffered a head injury which Jed to a subdural haematoma from which he did not recover. CIRCUMSTANCES OF THE DEATH Andrew Hogg began to have difficulties coping and was referred to adult social services in 2017. Efforts were made to assist him in the community but increasingly he was unable to cope due to his underlying Parkinson’s disease and possible dementia. He therefore moved into the Meadway Court Care Home on 20 April 2018 where he was resident until his death. Andrew had a history of falls and mobilised with a stick, although sometimes without it which increased his risk of falling. | heard evidence that staff were aware of his risk of falling but it was not clear what if any falls assessment had been undertaken. | was told that consideration was given to placing a falls mat beside Andrew’s bed in December 2018 but he declined this thinking it would be a trip hazard. Andrew then had a series of falls as follows:- 16.1.19 fail in lounge — cut forehead — paramedics attended 23.2.19 — unwitnessed fall in bedroom — cut on elbow 14,3.19 — unwitnessed fall in lounge — paramedics attended 30.3.19 — unwitnessed fall in bedroom 24.4.19 — witnessed fall in lounge area — cut to forehead - Paramedics attended 25.4.19 — fall in downstairs lounge — bang to head and lump on shoulder paramedics contacted however out of hours GP attended 26.4.19 — unwitnessed fall in bedroom - telephone advice from out of hours GP. On 1.5.19 the lump on the shoulder and bruising were more noticeable and Andrew was taken to hospital where a fractured clavicle was diagnosed. This was treated with support and he was discharged back to the Home on 2.5.19. Upon his return staff recognised Andrew was at high risk of falls and it was planned that Andrew should not walk alone and mobilization should be by wheelchair with one carer at all times. On 3 May 2019 Andrew was found on the floor of his room. An ambulance was called and he was admitted to Stepping Hill Hospital where CT scan revealed a large subdural haematoma. Following discussion with the neurosurgical team in Salford Royal Hospital it was concluded that Andrew would be unlikely to survive any operative intervention and palliative care was given until his death on 6 May 2019. 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. — | heard evidence of the sequence of falls which | have recounted above. While there may have been a falls assessment when Andrew first became resident at the home, there was no evidence before me of the nature and extent of that assessment. More particularly there was no evidence of any steps taken to review or reassess the falls risk following the falls Andrew had commencing in January 2019. There were some 7 falls before his final fall and it is a matter of concern that while each seems to have been dealt with reactively in that relevant assistance was sought, there were no steps considered to address what clearly was an escalating risk. In evidence | heard from who was the manager of the home (although | accept he was only recently in post). 7 having given evidence as to the facts above accepted that insufficient measures were taken to address the risks which were evident. In particular he identified that:- 1. Not all the relevant paperwork was completed following the falls 2. There could have been engagement with other services such as the local falls clinic 3. Consideration should have been given to using available equipment such as a sensor mat and “silent minder” 4. Relevant information should have been updated onto the patient's electronic record. While | welcome his insightful comments | remain concerned that 1. There was no adequate falls assessment policy 2. There was no obvious escalation pathway following the sequential falls Andrew had 3. There was no internal investigation into any of the falls which occurred 4, There was no consideration of steps which could have been taken to reduce the risk, whether by way of equipment or increased or more direct carer supervision. It seems to me that each incident was dealt with reactively and individually with no proactive consideration given steps which could be taken to reduce or ameliorate the risk of falling which quite obviously was increasing. While it cannot be said that had such steps been taken Andrew would not have fallen when he did, 1 do think that the risk of that happening would have been substantially reduced. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and 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 22" January 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 2 lO Andrew’s brother. | have sent a copy of my report to the Manager of the Meadway Court Care Home. | have sent a copy of my report to Stockport MBC Social Services Department. | have sent a copy of my report to the Care Quality Commission, who may find it useful or of interest. lam 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. Dated: 27" Nowe Signature: Christopher M Assistant Coroner, Manchester South.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Managing Director,
Glebelands Care Team,
Glebelands,
90, Love Lane,
Mitcham.
CR4 3DD.
1
CORONER
I am Dr Fiona J Wilcox, HM Senior Coroner, for the Coroner Area of Inner West London
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 13th November 2019, evidence was heard touching the death of Barry Jack
Gordon Liffen. Mr Liffen had died at St George’s Hospital on 11th May 2019, following
injuries sustained in a fall at his sheltered accommodation. He was 85 years old.
Medical Cause of Death
I (a) Hospital Acquired Pneumonia
(b) Subdural Haemorrhage
II Hypertension, Atrial Fibrillation (anticoagulated)
How, when, where Mr Liffen came by his death:
Mr Liffen suffered with dementia and other chronic illnesses which caused him to be
unsteady on mobilising. He was also taking anticoagulants for atrial fibrillation. On
10/3/2019, he fell in the night sustaining a head injury which caused subdural bleeding.
This progressed until his condition deteriorated such that an ambulance was called on
22/3/2019. He was admitted to Croydon University Hospital then St George’s Hospital.
The bleed stabilised but he developed recurrent pneumonia which ultimately took his life
on 11/5/2019 at St George’s Hospital.
Conclusion of the Coroner as to the death:
Accidental fall on a background of chronic medical illnesses and anticoagulation.
4
Extensive evidence was taken in court. In summary, of relevance to this report:
He lived at Glebelands in his own flat with 24 hr carers on site. By Oct/Nov 2018, his
care needs increased such that he needed 3 visits a day, help with personal care and
taking his medication. In 2019 he fell twice. The first time was 19th January 2019. He
was admitted to hospital and had a CT head scan on 21/02/2019 which did not show
any acute pathology.
He fell again on 10/3/2019 during the night. He was seen by Glebelands staff on the
floor and was unable to say how he had fallen. He got himself up and there were no
overt injuries but neither clinical assessment nor advise was sought by the attending
carers. He was initially well, but from 18th March 2019, he acutely deteriorated, such
that by 22/3/2019 an ambulance was called. At this point he could not feed himself,
communicate nor mobilise. He was admitted to hospital and found to have an
intracranial bleed and his anticoagulation stopped.
It is possible that had the head injury been diagnosed earlier, anticoagulation could have
been reversed earlier and the injury been less severe, such that the death may have
been avoided.
None of the carers attending Mr Liffen were clinically trained.
5
Concerns of the Coroner:
1. That clinical assessment be sought for frail persons resident at Glebelands
following falls.
2. That clinical assessment be sought for persons at Glebelands whose health
is noted to have deteriorated by staff.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
[AND/OR your organisation] have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report. 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 :
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
17th December 2019
Professor Fiona J Wilcox
HM Senior Coroner Inner West London
Westminster Coroner’s Court
65, Horseferry Road
London
SW1P 2ED
Honorary Professor QMUL School of Medicine and Dentistry
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.
-Bgreesh Life in colour Mr C Briggs HM Assistant Coroner Coroners Court 1 Mount Tabor Street Stockport SK1 3AG Date 02.01.2020 Re: Andrew Richard Hogg Dear Mr Briggs Thank you for your letter dated 26" November 2019 and the Regulation 28 served for my attention. Please accept my apology for the delay in my reply due to my being on Jury Service, Illness and Christmas Holidays. [have investiagted your concerns and I agree that each fall had been dealt with appropriately, but a review into the number of falls and the timescale in which the falls occurred did not appear to happen at that time. In our other homes the falls would be reviewed at least monthly following the actioning of the SMBC Safeguarding log. Home managers would have escalated the level of falls to the GP or the falls clinic. ! feel that due to Mr Witon being a new manager this process was overlooked. He had only been with the business a matter of a few weeks and was still working though his induction process. However, to tighten up our process all home managers will be reviewing falls on our PCS (Person Centered Software) system on a weekly basis to ensure that falls are monitored more frequenty. Managers will print the falls log for the week and add notes as to what actions have been taken. These notes will also be added to the support plans of those residents involved. Collectively as a group of managers we have also agreed that any resident who has more than two falls within a two week period we will arrange a review with their GP or CPN. Borough Care Limited T: 0161 4750140 A: 9 Acom Businass Pork E: enquirles@boroughcare.arg uk Heaton Lane. Stockport SK4 1AS W: boroughcare.org.uk Bermegt Care Lorvted br on inutustrind ond Proveiertt Society with chartable vixtwe. Repictared Offies. 0 Aemen Nusinens Perk. Heaton Lars Stect sant SK4 1A5 Rayiotered marian 2778251 This process will be reviewed by our Area Managers as part of their monthly audit. To aid managers to complete this task weekly | have added this action to our managers strategic calendar which prompts them daily, weekly monthy etc to actions required. I hope that you feel that we have taken prompt actions and reviewed our practise to your satisfaction. Please feel free to contact me if you require any further information. Yours Faithfully Head of Care Services.
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