Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0171, written 8 Sep 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 Sep 2020 |
|---|---|
| Reference | 2020-0171 |
| Deceased | Peter Howarth |
| Coroner | Chris Morris |
| Coroner area | Greater Manchester South |
| Category | Care Home Health related deaths · Hospital Death (Clinical Procedures and medical management) 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Mr_ Officer, Borough Care, 9 Acom Business Park, Heaton Lane, Stockport SK41AS , Chief Executive 1 CORONER I am Chris Morris, Area Coroner for Greater Manchester South. 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST -....._ On 22nd October 2019, I opened an inquest into the death of Peter William Howarth who died at Stepping Hill Hospital, Stockport on 10th October 2019 aged 83 years. The investigation concluded with the inquest which I heard on 7th July 2020. The court heard evidence that Mr Howarth died as a consequence of:- 1 a) Cardiac failure; b) Cerebrovascular disease; II Dementia, frequent falls, rib fractures, lfractured neck of femur (operated). I The inquest concluded with a narrative conclusion to the effect that Mr Howarth died as a consequence of natural causes contributed to by consequences of injuries sustained in a number of falls. 11 4 CIRCUMSTANCES OF THE DEATH I I I ! Mr Howarth, who had a complex medical history, was admitted to hospital on 9th October 2019 having sustained injuries in a fall at Brynhaven Rest Home in Stockport. Whilst in hospital, Mr Howarth had anotherjfall, as a consequence of which he suffered a· fractured neck of femur which required surgery. IMr Howarth died in hospital as a consequence of complex underlying health oroblems combined with iniuries sustained in a number of falls. 1 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. The court heard evidence that, despite the fact Mr Howarth was injured in a fall at his care home which led to his final admission to hospital, Borough Care has not undertaken any investigation into the circumstances of that fall. Robust investigations into falls in care and nursing homes are essential with a view to considering whether or not there is any learning to be derived from the incident for the benefit of other residents with a view to reducing the risk of death arising from falls in similar circumstances. 6 ACTION SHOULD BE TAKEN ~----·· In my opinion action should be taken to prevent future deaths and I 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 3rd November 2020. I, the coroner, may extend the period. 1 1 1 Your response must tbontain 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 1have sent a copy of ~Y report to the Chief Coroner and to Mrs - - as the family•s legal representative, in addition to Ms - Browne Jacobson LLP who acted on behalf of Stockport NHS Foundation Trust. I am also under a duty to send the Chief Coroner a copy of your response. of The report will be copied to the Care Quality Commission and Stockport Metropolitan BorougH Council, who may find it useful or of interest. 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 . 2 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 s HM Area Coroner 08.09.2020 - ---= ._ -- ----- - ll ll 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.
Mr C Morris HM Coroners Office 1 Mount Tabor St. Stockport SK1 3AG Date: 29th September 2020 Re: Reg 28 dated 07.09.2020 Re Peter Howarth Dear Mr Morris Thank you for your correspondence. We had previously received a REG 28 on 28.11.19 relating to falls and have put extra measures in place to review falls on a weekly/monthly basis as a result. Below is a time line of events: Death of Andrew Hogg Inquest of Andrew Hogg REG 28 received Manager Meeting Reply to Coroner Death of Peter Howarth Inquest of Peter Howarth 06.05.19 06.10.19 26.11.19 28.11.19 02.01.20 10.09.19 07.07.20 At the Manager meeting on the 28th November 2019 we discussed the new procedures for reviewing falls in all Borough Care homes. Managers must now complete a weekly falls analysis and detail all actions taken. If a resident has more than 2 falls in any period of 2 weeks a referral must be made to their GP or to the falls clinic. Managers must also complete a monthy review to ensure the safety of all residents and hilight any trends that may be contributing to the falls within the home. As you can see from the timeline above these extra measures were implemented after the inquest of Andrew Hogg. The additional measures were therfore not in place when Peter Howarth fell, but were in place before the inquest into the death of Peter Howarth. All these measures have been discussed with CQC and our policy has been updated to reflect the extra analysis and actions. I have attached the previous correspondence with the Coroner in relation to the earlier REG28, re falls. I hope this meets with your approval. Please do not hesitate to contact me if your require any further information. Regards Head of Care
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