Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0452, written 24 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 | 24 Dec 2019 |
|---|---|
| Reference | 2019-0452 |
| Deceased | Keith Whetton |
| Coroner | Andrew Haigh |
| Coroner area | Staffordshire (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.
Her Majesty's Coroner Staffordshire (South) Coroner's Jurisdiction Date: 24 December 2019 Case: 1648196 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Hunters Lodge Care Home Hollybush Lane Codsall WV8 2AT 1. CORONER’S LEGAL POWERS | am Andrew A Haigh Senior Coroner for Staffordshire South | 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. 2. INVESTIGATION and INQUEST On 23 October 2019 | commenced an investigation into the death of Keith Graham WHETTON. The investigation concluded at the end of the inquest. The conclusion of the inquest was An elderly man in declining health who fell in a care home. The cause of death was: 1a End Stage Dementia and frailty Il Fracture right neck of femur 3. CIRCUMSTANCES OF THE DEATH Keith had an unwitnessed fall in his room at Hunters Lodge Care Facility on the 07.09.19. attended as part of his Monday morning visit to the care home on the 09.09.19. He then sent Keith to New Cross Hospital Wolverhampton on the 09.09.19, where he was found to have a fractured right hip. He was then operated on and had a hemiarthroplasty and remained in hospital, until he was discharged back to the Care home on the 27.09.19. Sadly he continued to deteriorate and died at the home on the 05.10.19 1 Staffordshire Place, Stafford, ST16 2LP Telephone: 01785 276126 or 276127 Email: sscor@staffordshire.gov.uk 4. 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. 5. The MATTERS OF CONCERN are as follows. — You should already be aware of the concerns in this matter. Even if medical attention was not sought for Keith on 7'* September it clearly should have been requested on 8th September. We hope that this has now been taken on board by your home. Additionally, family members felt that they should have been informed earlier about Keith’s fall and | wonder if lessons have been learned here as well. 6. 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. 7. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 18.2.2020. |, 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons — the family of the deceased. | have also sent it to Staffordshire County Council Adult Safeguarding and the éare 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. 9. Signature 24 December 2019 Senior Coroner for Staffordshire South 1 Staffordshire Place, Stafford, ST16 2LP Telephone: 01785 276126 or 276127 Email: sscor@staffordshire.gov.uk
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.
@ InteRhAzeE Ltd Hunters Lodge Care Centre Hollybush Lane, Codsall, Wolverhampton WV8 2AT | Tel: 01902 847575 | hunterslodge@interhaze.co.uk Hunters Lodge Care Centre Hollybush Lane Codsall Wolverhampton WV8 2AT 27/01/2020 Dear Andrew Haigh | am writing to you in response of the letter you sent to myself regarding Keith Graham Whetton (deceased). After reviewing the coroners report we have been through your concerns and we have already addressed the concerns that you have highlighted, to try to prevent future deaths. Following the fall all staff have been supervised on the matter and have completed falls training. Trained staff are going to be commenced on additional training via remit training group. | myself and the clinical lead have completed the course and believe it will be beneficial for other senior staff to complete. | have also reviewed the policy and procedure of falls within the home and spoken with the regional mangers regarding unwitnessed falls and the policy and procedure has now been updated and put in place within the home. The policy is now more robust and has clear instructions on steps to be taken in the event of a fall. After my trend analysis and internal investigation | have increased staffing levels to increase observation of residents and further support to the nursing team. This level of support has had a positive impact in reducing falls and improving patient safety. | believe that actions taken have improved the service, especially around patient safety. | feel we have all learned lessons regarding this matter and as a service we will continue to strive to improve the care we deliver to our clients and families. If there is any further information you require please do not hesitate to ask. Yours Sincerely anager Head Office: Interhaze Ltd, Hunters Lodge, Hollybush Lane, Codsall WV8 2AT Tel: 01902 847575 | Info@interhaze.co.uk | www.interhaze.co.uk A perfect home away from home, where Compassion and Care Come ToGeTheR
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