Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0427, written 17 Dec 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Dec 2019 |
|---|---|
| Reference | 2019-0427 |
| Deceased | Iris Skinner |
| Coroner | Anna Crawford |
| Coroner area | Surrey |
| 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.
IN THE SURREY CORONER’S COURT IN THE MATTER OF: The Inquest Touching the Death of Iris Irene SKINNER A Regulation 28 Report — Action to Prevent Future Deaths THIS REPORT IS BEING SENT TO: • Dr Pete Calvely, Chief Executive Officer Barchester Healthcare 3rd Floor The Aspect 12 Finsbury Square London EC2A lAS 2 3 4 CORONER Miss Anna Crawford, HM Assistant Coroner for Surrey CORONER’S LEGAL POWERS I make this report under paragraph 7(1) of Schedule 5 to The Coroners and Justice Act 2009. INQUEST The inquest into the death of Mrs Skinner was opened on 31 October 2018. It was resumed on 26 November 2019 and the conclusion was handed down on 27 November 2019. The medical cause of Iris Skinner’s death was: la. Intra-cranial haemorrhage lb.Fall 2. Mixed Dementia (Vascular and Alzheimer’s Dementia) The inquest concluded with a short-form conclusion of ‘Accident’. 1 5 CIRCUMSTANCES OF THE DEATH Mrs Skinner was a resident at Windmill Manor Care Home in Oxted which is run by Barchester Healthcare. On 1$ October 201$ she lost her balance and fell over whilst at the care home. She was taken to East Surrey Hospital the following day on 19 October 201$, where she was found to have sustained a fatal head injury. She died at East Surrey Hospital on 23 October 2018. At the inquest the Coroner found that there were a number of omissions in relation to the management of Mrs Skinner following the fall: - There was an omission to sufficiently frequent neurological observation, as well as a complete omission to carry out any observations from midnight to 7am on 1$ October 2018, in breach of the Barchester Healthcare head injury policy. carry out - The observations which were carried out were not sufficiently comprehensive in that there was an omission to record both Mrs Skinner’s temperature and respiratory rate on all but one occasion, again in breach of the Barchester Healthcare head injury policy. - As a result of those omissions it has not been possible to establish precisely when Mrs Skinner’s condition began to deteriorate and whether an admission to hospital would have been indicated at some point during the course of the night. - At 9.3Oam on the morning of 19 October 2018 Mrs Skinner was observed to have vomited and to be unresponsive. Thereafter there was a significant delay, the reasons for which remain unknown, in the calling of an ambulance, which was not called until 11.22am, again in breach of the Barchester Healthcare head injury policy. The omissions identified in Mrs Skinner’s care did not cause or contribute to her death. However, the reoccurrence of which would present a risk to the lives of current residents. they remain a matter of serious concern, 2 6 CORONER’S CONCERNS The Coroner’s concerns are as follows: The Barchester Healthcare Head Injury Policy is a comprehensive policy which sets out the appropriate response to implement when a resident is suspected of having sustained a head injury. The court heard evidence from Jayne Holloway, a Regional Director for Barchester Healthcare who informed the court that since Mrs Skinner’s death all trained permanent staff at the home have been asked to confirm that they have read and are familiar with the Head Injury policy. However, the court also heard evidence that a significant number of agency staff are employed by the home and that the same process has not been followed in respect of agency staff. The MATTER OF CONCERN is: - Agency staff employed by Windmill Manor Care Home in Oxted, and potentially more broadly across the Barchester Healthcare group, may be unfamiliar with the Barchester Healthcare Head Injury Policy. 7 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that the people listed in paragraph one above have the power to take such action. 8 YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed. 3 9 COPIES I have sent a copy of this report to the following: 1. Chief Coroner 2. 3. Care Quality Commission Iris Skinner’s family 10 Signed: Anna Crawford H.M Assistant Coroner for Surrey Dated this 17th day of December 2019 4
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.
BARCHESTER Ce&.brat, fe Her Majesty’s Assistant Coroner Anna Crawford Woking Coroner’s Court Station Approach Woking Surrey GU22 7AP 18th February 2020 Dear Madam Coroner, Inquest touching the death of Iris Skinner Prevention of future death report - Windmill Manor Care Home, Oxted Surrey I write further to the conclusion of the inquest of Ms Iris Skinner held on 26-2 7 November 2019. Barchester Healthcare were granted Interested Party status in respect of these proceedings. I am in receipt of your Regulation 28 Report — Action to Prevent Future Deaths dated 17 December 2019 and note the matter of concern is that agency staff employed by Windmill Manor Care Home in Oxted, and potentially more broadly across the Barchester Healthcare group, may be unfamiliar with the Barchester Healthcare Head Injury Policy. Please find the actions taken and planned in Windmill Manor and across Barchester homes in order to address this matter of concern. A copy of this information has also been supplied to the Care Quality Commission. At Windmill Manor the specific actions that have been taken include: A new Agency Folder is now in place in the home with printed copies of all the key policies, this includes Falls management, Head injury, Management of Medications, Choking, Tissue Viability, Bed Rail Assessment and Safeguarding of Vulnerable Adults. The file also contains the relevant contact details i.e. General Manager, Clinical Development Nurse, Regional Director, GP who would be available to provide advice and support should it be required. All agency nurses are then allocated time to review the information and are required to Barchester Healthcare Ltd Baicliestr I Iealthtire Ltd .3rd Floor, The Aspect, 12 hnsI)tIrv Sqtiare, London, EC2A lAS Tel: t)2f) 7382 28(() • Fax: 02t) 7382 289() • Email: info@barchester.com • www.hurchester.com RetWied iii England Nn. 27922i15 BARCHESTER Ceriv fer sign that they have seen and read this as part of their induction prior to commencing their shift. I attach evidence of the documents which have been completed by the two agency staff who have been in the (pdf: Staff home since December 2019 and reviewed the file Signatures and pdf Agency Induction Record 01 and pdf Agency induction record LN). • Notices have been put on each community staff notice board in relation to the new procedure for agency nurse induction and the General Manager has planned to speak to each individual nurse 1 attach evidence that regarding the changes by 17th January 2020. (pdf: Staff two Barchester Nurses have already been updated. signatures] • The General Manager at Windmill Manor has also contacted the agency providers to inform them of the new processes in relation to the responsibilities of the agency staff accessing the available file which contains the key policies. • The General Manager at Windmill Manor has also agreed to complete spot checks with agency nurses on duty to test their knowledge to ensure they have read and understood the policies. • In addition all the Nurses’ stations in the home have been provided with an up to date copy of the Royal Marsden Handbook of Clinical Practice which provides guidance on management of clinical conditions including head injury and falls management. As a company, we have thoroughly reviewed our current procedures and processes in relation to lessons learnt in this case and are also making some changes to our processes. • Our Policies are currently located on our internal intranet site and accessible through our home computers and via the Learning and Development training tablets in each home. Homes may print off the policies for staff, however there is a risk that the most recent policy may not be the one in use at that time as they are regularly updated in line with new practices and external body recommendations such as NICE/NMC/CQC. The policies are all version controlled and the Barchester Ilealtheare Ltd l3archistt’r i1calEh(a1c Ltd. 3rd Floor. Th Asiwct. 12 Fifl,l)tIrv St1wtn. London. EC2A lAS Tel: 1)20 7382 286() • Email: ink)tu:1)archcster.com vww.barchetcrrom Fax: t)2() 7382 2801) Rtttid in England Nn. 27922H5 BARCHESTER organisation is informed via our electronic weekly communication ‘iBarchester’ of any changes or updates to any policy to minimise the risk of homes using an old policy. • As part of our Quality Governance Framework Barchester Healthcare has a ‘Policy on policies’ which identifies the process, formulation and format of all our organisational polices. At the beginning of each policy there are ‘Key policy points listed’ which summarise and identify for quick reference the key messages and practices in each of the policies. • The Director of Nursing, as the policy owner, is currently identifying 10 key policies in which the Head injury and Falls policy will be included, and will condense the key points into a pocket guide for all agency staff. • The pocket guide will have an FAQ section and also space to complete the details of who the agency nurse can contact whilst on duty for advice during their shift; this may be another nurse on duty in the home, the General Manager or the person in charge that has handed over to the agency staff member in the previous shift. • To supplement the pocket guide, in the home staff room there will be a wall mounted commercially produced poster which contains very similar information as the pocket guide and will provide a reference point for all staff in the home in relation to key policy information. • The timeframe for completing the printing and introduction across all the Barchester homes for the modified induction checklist, pocket guide and poster is the end of February 2020. We would be pleased to send a copy of the pocket guide format to you once the pocket guide has been produced. • Currently all Agency workers in a Barchester home complete an agency worker induction prior to working in the home and the new pocket guide development will be added to the agency worker induction check list once it has been produced and in use. • To monitor compliance against the new agency induction checklist which will include distribution of the pocket guides and signatures on Barchester Ilealthcare Ltd Harchc’stci’ It( Llthcir’ Ltd. 3rd Fiuui. The Aspect. 12 Fiiishurv Scjtwt’c, London, EC2A lAS tel: ()2() 7382 286() Email: infotharcIwster.coni Fax: t)2() 7382 28)() • www.haiclwstei.com Rcgiskiecl in IngIand No. 2Q22i5 BAPCHESTER IeJrat, tVe the induction checklist this will be checked by the Regional Directors and Audit programme across Barchester homes as part of the overarching Quality Governance Framework. is hoped that following receipt of this correspondence and the enclosed It documentation, you may be reassured that Barchester Healthcare has taken significant steps to address the matter of concern you identified. I hope this provides you with the information needed to consider this matter. Should you require any further information, please do not hesitate to contact me. Yours sincerely, (Z Director of Nursing Barchester Healthcare Ltd BUch(’St(’t’ t1c lthClre Ltd. 3rd floor, ‘fhe Aspect. 12 Finsbui Squwe. London. EQ2A lAS Tel: 02t) 382 2860 • Fax: 02() 7382 2$9() • Email: iflfc)(ba1chcster.com www.haichester.com ItitecI in 1ngIand No. 27922S5
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