Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0098, written 22 Apr 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Apr 2020 |
|---|---|
| Reference | 2020-0098 |
| Deceased | Norman Baxter |
| Coroner | Chris Morris |
| Coroner area | Manchester South |
| 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
278 Buxton Road, Great Moor, Stockport, SK2 7AN
Registered Manager, Lynmere Nursing Home,
CORONER
I am Chris Morris, Area Coroner for Greater Manchester South.
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.
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 28th August 2019, Alison Mutch OBE, Senior Coroner for Manchester South, opened an inquest
into the death of Norman Baxter, who died at Stepping Hill Hospital Stockport on 8th August 2019
aged 87 years.
The coronial investigation concluded with the inquest which I heard on 18th and 21st February 2020.
At inquest, it was determined Mr Baxter died as a consequence of
1) a) Severe sepsis and septic shock
b) Infective exacerbation of Chronic Obstructive Pulmonary Disease and e-coli infection of
unconfirmed origin.
II) Type 2 diabetes, probable myeloma, previous hip fracture resulting in girdlestone procedure.
The inquest concluded with a narrative conclusion, to the effect that Mr Baxter died as a
consequence of complications of Chronic Obstructive Pulmonary Disease and an e-coli infection.
Whilst this is a natural cause of death, it is likely his death was contributed to in part by a previous
hip fracture sustained in hospital which ultimately required a girdlestone procedure.
CIRCUMASTANCES OF THE DEATH
Mr Baxter had been slowing down and showing signs of decline when he was admitted to Stepping
Hill Hospital, Stockport in December 2018. There, he underwent investigations amidst a concern he
was suffering from myeloma. An incidental finding on one such investigation was an undisplaced
subcapital hip fracture which required surgery. A hemiarthroplasty was performed, but Mr Baxter
ultimately required a girdlestone procedure having fallen again on the ward and dislocating his
prosthetic hip.
Once medically fit for discharge, Mr Baxter required nursing care and as such moved into Lynmere
Nursing Home in Stockport. There he settled well essentially, but from time-to-time developed
chest infections.
On 7th August 2019, a carer noticed Mr Baxter had become unwell. A Registered Nurse working an
agency shift took observations throughout the day, but several hours passed before an ambulance
was finally called. Mr Baxter died in hospital the following day.
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. –
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and your
organisation have the power to take such action.
1. The court heard evidence that, at the time Mr Baxter was cared for at Lynmere, nursing
observation charts were not in use. Nursing observation charts, when completed, may assist
staff in appreciating an acute episode of illness, or deterioration in a resident’s condition.
This may particularly be the case were the observation chart to be used in conjunction with
a system such as NEWS2, an aggregate scoring system intended to standardise the
assessment of, and response to, acute illness.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by
16th June 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
I have sent a copy of my report to the Chief Coroner and to Mr Baxter’s son and daughter-in-law.
I have also sent it to the Care Quality Commission and Stockport MBC who may find it useful or of
interest.
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.
Dated:
22nd April 2020
Signature:
Chris Morris HM Area Coroner, Manchester South.
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.
Dear Mr Christopher Morris I am in receipt of your email and Regulation 28 report. I wish to advise that following the Inquest, a discussion between myself and the previous manager took place and the following was put into place with immediate effect. 1. The News Scoring System 2. NEWS 2 Chart 1,2,3 (observation chart),and 4 3. Algorithm for managing suspected sepsis in adults and young people aged 18 years and over, outside an acute hospital setting. Sepsis risk stratisfication tool 4. Sepsis guidance implementation advice for adults This was followed up by one to one discussions with all our Nursing staff confirming their understanding and how to use the tools. the acting manager has also been made aware of the contents of the Regulation 28 report and I wish to confirm that these tools are being used and that any new nursing staff recruited since have also been made aware. Any agency staff that work at Lynmere are also advised of the use of these tools and their importance. If I or my Manager, contact us. Kind Regards can be of any further assistance please do not hesitate to RMD Care Services Ltd t/a Lynmere Nursing Home
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