Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0109, written 12 Feb 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Feb 2020 |
|---|---|
| Reference | 2020-0109 |
| Deceased | Donald Elliott |
| Coroner | Paul Cooper |
| Coroner area | Lincolnshire |
| Category | Care Home Health related deaths · Other 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 (1) NOTE: This from is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Glenholme Holdingham Grange Care Home 1 CORONER I am Paul COOPER, HM Assistant Coroner for the area of Lincolnshire 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 05/03/2019 I commenced an investigation into the death of Donald George ELLIOTT aged 88. The investigation concluded at the end of the inquest on 07 February 2020. The conclusion of the inquest was: I a Intracranial Haemorrhage I b I c II Parkinson's Disease, Dementia, Heart Failure. 4 CIRCUMSTANCES OF THE DEATH The deceased was cared for at Glenholme Holdingham Grange, Whittle Road, Holdingham, Sleaford. Following at least one fall in the home (that was witnessed) on 31st January 2019 as a result of which on the balance of probabilities the deceased hit his head on the floor (although this was not witnessed) .The deceased was taken to hospital where he stayed until 9th February 2019. He was then discharged back to the home and was nursed in bed until he died on 22nd February 2019. 5 CORONER’S CONCERNS The MATTERS OF CONCERNS are as follows: (brief summary of matters of concern) 1. deceased was recorded as falling. Please confirm the level of staffing present on 24/01/2019 and 31/01/2019 at the time the 2. Regulation 18 Health and Social Care Act 2008 as to: Is the Care Home able to evidence and demonstrate on both dates they complied with a) Deploying enough suitably qualified competent and experienced staff and, b) appraisals that are necessary for them to carry out their role and responsibilities. That those staff received the support, training, professional development, supervision and This report is raised due to the contradictory evidence filed in the Inquest for and on behalf of 3. Glenholme Holdingham Grange Care Home and to ascertain why the coronial service was only notified the day before the Inquest why 2 witnesses formerly engaged by the Care Home failed to attend the inquest under summons. An explanation of which is required as to what efforts and resources were deployed to locate them by a manager/director. 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, namely by 08 April 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. 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 Paul COOPER HM Assistant Coroner for Lincolnshire Dated: 12 February 2020
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.
2 11 1 r:~"O . LvL HOLDINGHAM GRANGE INVESTIGATION REPORT RE The late Donald Elliott (DE) 17.08.30 BACKGROUND Mr Elliott was admitted to Holdingham Grange, from another care home, in August 2018 in order to be nearer to his wife ; who lives in Sleaford . DE was at a high risk of falling ; which was highlighted in the risk assessment and an appropriate care plan was developed . He walked with a frame but frequently tripped over his feet and his frame. He used a wheelchair for distances. He had a sensor mat next to his bed to alert staff when he was up, which he agreed to. Other than that staff observed him as was normal in the course of the day. He was able to use his call bell and , although forgetful , he did ring most of the time . He was never funded for or deemed that he required 1-1 observation. He was funded for nursing care. He was visited by his wife most days. He came up for meals into the dining areas and socialised with others. He had capacity to make decisions about where he wanted to go and what he wanted to do . He was sometimes confused to time and place but was easily reassured and re orientated . He lived on the Nursing unit initially, as th is was the only unit that was open. He moved onto the dementia unit when it opened on 7th January 2019. At that time the staff ratio was 2 staff to 4 residents in the day and 1 carer and nurse floating at night, (3 residents were residential and 1 was nursing). CONCERN Coroner raised some questions which required a response by April 8th 2020 : Staffing levels on both days, when Mr Elliott to confirm we had sufficient suitably trained staff Why 2 staff called to attend the inquest did not attend If staff received support, supervisions and appraisals to enable them to carry out their roles and responsibilities . INVESTIGATION METHODOLOGY Interviews with staff present during incident • Care records • • Rotas • Allocation sheets • Resident occupancy sheets • Accident reports FINDINGS 24.01 .19 There were two staff on duty during the day and one carer and a 'floating ' nurse at night. There were four residents on the unit. 31.01 .19 There was a registered nurse and an agency carer on the unit when he fell. Staff to resident ratio was 2-4 at the time of the fall. The fall was witnessed by the carer who did not see him hit his head. He was checked over by the nurse who was giving medication at the time. The investigation has demonstrated that there were sufficient, suitably qualified , staff on duty on 24.01 .19 and 31 .01 .19 to meet the needs of the residents occupying the home at the time. Agency staff on duty at the time had received appropriate training through their agency; which was evidenced within the contract with them . The same agency staff attended the home to maintain continuity . 24.01 .10: Staffing levels during the day included ; the Registered nurse manager, a registered nurse and 4 care staff and an activities person in the day and one registered nurse and two care staff at night. The total number of residents in the home on the 24.01 .19 were 27. Eight of which required nursing care and the remaining required social and personal care. 31 .01.19: Staffing levels on this day were I registered nurse manager, 2 nurses and 9 carers and an activities person , one carer being on induction day, and the second nurse was supernumery for care planning a ratio of 1-3, and 1 nurse and 2 carers at night, a ratio of 1-8 28 residents were in the home in total 8 requiring nursing care and the remaining social and personal care DE had not been assessed as requiring 1-1 care therefore usual observations and checks were undertaken. Staff complete training before commencing employment. During the probation period a full induction is completed and supervision is provided. Staff with prior care experience are employed where possible. No summons was received by the manager or any other staff to attend the inquest. Please accept our apologies as none of the staff would knowingly not attend . . Actions: We have reviewed all our falls risk assessments we work in partnership with OTs to discuss suitable equipment and this is ongoing and falls training is available for all staff. Registered Manger 27 .03.2020
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