Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0126, written 8 Jun 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Jun 2020 |
|---|---|
| Reference | 2020-0126 |
| Deceased | Mildred Horrex |
| Coroner | Penelope Schofield |
| Coroner area | West Sussex |
| 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 THIS REPORT IS BEING SENT TO: The Manager Pelham House (Cedarcare (SE) Ltd Cuckfield West Sussex RH17 1 CORONER I am PENELOPE SCHOFIELD, senior coroner, for the coroner area of WEST SUSSEX 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 22nd January 2018 I commenced an investigation into the death of Mildred Horrex, aged 85 years. The investigation concluded at the end of the inquest on 3rd October 2018. The conclusion of the inquest was that Mildred Horrex died an “Accidential death”. At the conclusion of the Inquest indicated that I was minded to make a Regulation 28 report. Regretably whilst the indication to make a Regulation 28 report was made in October 2018 it appears to have been missed and was not issued until June 2020 for which I apologise. 1 4 CIRCUMSTANCES OF THE DEATH On 30th December 2017 Mrs Horrex, who was left sleeping in a chair in her room at Pelham House, suffered an unwitnessed fall in which she suffered a fracture to her C1 and C2 vertebrae in her neck. She was taken to hospital but sadly did not recover from her injuries and she died on 18th January 2018. 5 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. – 1. During the course of the Inquest it was clear that overall the record keeping in respect of Mildred was poor. There was insufficient information taken about Mildred by the home before her admission to Pelham House, the information that was taken was at times inaccurate and this lead to an inadequare fall risk assessment being insufficient. 2. Whilst the drugs chart showed that Mildred was taking her medication regularly the amount of medication that was found after her death showed that this could not be the case. We were told that monthly drugs audits were apparently carried out but they did not pick up the decrepancies in the recording on the drugs charts and the amount of medication held. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 4th August 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:- The family of Mildred Horrex 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 Date 8th June 2020 2 Penelope Schofield, Senior Coroner 3
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.
Action Plan: Regulation 28 Report to prevent Future Deaths MH Point 1 Matter of Concern During the course of the Inquest it was clear that overall the record keeping in respect of Mildred was poor. There was insufficient information taken about Mildred by the home before her admission to Pelham House, the information that was taken was at times inaccurate and this lead to an inadequate fall risk assessment being insufficient. Response Prior to admission the family had a meeting with the manager of the home and the deputy manager, they themselves provided all the information to us everything they believed relevant, my deputy questioned them about falls history and they said mum is NOT a high risk of falling having only one fall whilst in her own home, all information was provided by themselves, the risk assessment was sufficient at the time it was extremely difficult to explain the workings of the system in a court room with individuals that have never used a care plan system before I believe this is why the coroner made the comment about record keeping, ( the paramedic in the court room understood perfectly well as he was familiar with the system) the system we used took the information provided by the family and generated a falls score, MH had not fallen in Pelham prior to her death and this meant that a falls referral would not be necessary, this is done after two falls or more and the information the family provided by the family did not warrant a referral, we are a Residential home not a nursing home and GPs do referrals or care homes. Point 2 Matter of Concern Whilst the drugs chart showed that Mildred was taking her medication regularly the amount of medication that was found after her death showed that this could not be the case. We were told that monthly drugs audits were apparently carried out but they did not pick up the discrepancies in the recording on the drugs charts and the amount of medication held. Response At the time of this incident visual medication spot checks were carried out by the Deputy Manager along with daily audits and monthly summaries. Assessing the competency of Senior staff administering medication is ongoing with a Senior member of staff that is a trained medical assessor and promotes in house training. Policies and procedures covering medication in the Home are well documented and accessible by all staff. Questionnaires on medication relating to the policies and procedures are used in the home as refresher tools for all care staff and all staff have training twice a year and an online course. Pelham house response of actions taken. POINT 1 Pelham house restructured the whole pre-assessment process the paper work was updated and now reflects all aspects of an individual’s ADL as well as the existing questions ( this was already in place just with some more information areas to highlight and family members are now signing the pre-assessment forms to agree to what has been documented) family members continue to sit with management and go through the individuals life and health history the family still continue to assist with the care planning with the individual present so we can get a good understanding of need, we also now have recorded calls something that would have been very beneficial at the time of MH arrival and passing, we also have a new care plan system that is recognised by CQC and this is working very well and has all information risk assessments and an audit trail, it allows a gateway should relatives with to log in and see what’s happening on a daily basis, Pelham house also employs an external auditor who comes to audit monthly and sooner where needed and is always available for advice all care plans and risk assessments are reviewed monthly and where needed if a change has occurred, and relatives have care plan reviews that are now signed, All staff have a log in to all policy & procedure on our external site there is a clear and concise falls procedure and all staff and new staff are required to read and act accordingly should a fall happen, ( this was also in place at the time of the fall ) we already work closely with the falls teams and occupational health. POINT 2 medication Medication is audited monthly CCG / Kamsons pharmacy myself and the GP have worked together to ensure safe practices are ongoing, Home manager Audits internally alongside the deputy manager and there is a visible summery at the end of the audit to highlight any potential concerns. External auditor also audits medication and administration when he visits. There is ongoing support from the CCG and Kamsons pharmacy After a request from myself GPs now provide patient summaries for all residents that are currently in Pelham house and coming in to Pelham house.
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