Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0227, written 9 Nov 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Nov 2020 |
|---|---|
| Reference | 2020-0227 |
| Deceased | Joseph Hargreaves |
| Coroner | Alison Mutch |
| Coroner area | Greater Manchester South |
| Category | Care Home Health related deaths |
| Organisation named | Stockport NHS Foundation Trust |
| 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.
poacmaeese54 REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Secretary of State for Health and Social Care CORONER'S LEGAL POWERS CORONER | 1am Alison Mutch, Senior Coroner, for the Coroner Area of Greater | Manchester 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 | INVESTIGATION and INQUEST On 24" April 2020 | commenced an investigation into the death of Joseph | Hargreaves. The investigation concluded on the 29 November 2020 and the conclusion was one of Narrative: Died as a consequence of the The medical cause of death was 1a) Sepsis; 1b) Aspiration Pneumonia | ! on a background of chronic swallowing difficulties; Il) Congestive Cardiac Failure, Ischaemic Heart Disease, Hypertension 4 | CIRCUMSTANCES OF THE DEATH On 17th April 2020, Joseph Hargreaves had an unwitnessed fall at his care home. The precise circumstances are unclear. He was admitted to Stepif Hill Hospital where he was treated for sepsis due to aspiration pneumpnia, caused by poor swallowing. He appeared to improve initially’ | but deteriorated rapidly when transferred. He died at Stepping Hill | Hospital on 17th April 2020. | 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. — The induest heard that Mr Hargreaves was a long-term rebident of the care home with significant swallowing issues and poor mobility. Following fockdown his family, who had been visiting most days, could no longer -——~| complications of underlying swallowing difficulties senor kaa anaemia aan canmare wenn | hospital and they were unclear about the events in the home leading up to his admission. The provision of information, about the events leading up to his admission; his baseline and underlying health issues, to treating clinicians was reduced. In his case it did not impact the outcome however it was clear from the evidence that it could in other circumstances cause significant challenges in delivering effective treatment quickly to vulnerable patients. 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. TYouR RESPONSE You are under a duty to respond to this report within 56 days of the date | of this report, namely by 4°" January 2021. |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be why no action is proposed. 4 ane taken, setting out the timetable for action. Otherwise you must explain 8 cores and PUBLICATION | | have sent a copy of my report to the Chief Coroner and to the following Interested Persons, namely daughter of the deceased, and the management of Bankfield House Care Home, 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 youl response by the Chief Coroner. Alison Mutch HM Senior Coroner 09.11.2020
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.
From Nadine Dorries MP Minister of State for Patient Safety, Suicide Prevention and Mental Health 39 Victoria Street London SW1H 0EU 2 February 2021 Your Ref: Our Ref: Ms Alison Mutch HM Senior Coroner, Manchester South HM Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG Dear Ms Mutch, Thank you for your letter of 9 November 2020 to Matt Hancock about the death of Joseph Hargreaves. I am responding as Minister with responsibility for hospital care quality and patient safety and I am grateful for the additional time in which to do so. First, I would like to offer my deepest condolences to the family and loved ones of Joseph Hargreaves. I am truly sorry that the circumstances surrounding Mr Hargreaves’ death during the emergency period of the COVID-19 pandemic, meant that they were unable to visit Mr Hargreaves at his care home or to accompany him to hospital. I understand how deeply upsetting this must be. I have noted and appreciate your concern about the potential impact this could have on outcomes for vulnerable people where clinicians have reduced information available to them. Patient safety is our top priority, which is why the NHS has stringent infection control measures in place to prevent the spread of coronavirus to vulnerable hospital patients. This includes managing visits in a safe and COVID-secure way. On 13 October 2020, NHS England revised its guidance on how NHS organisations may choose to facilitate visiting across healthcare inpatient, outpatient and diagnostic service settings during the COVID-19 pandemic1. Visiting is subject to local discretion by NHS trusts and other NHS bodies, and will take the local prevalence of COVID-19 into account. We recognise the importance of being able to visit family, friends and loved ones in hospital, particularly during this difficult time, and endorse the latest guidance which advises NHS bodies and trusts to take a more compassionate and caring approach to hospital visiting compared to the previous guidance published on 5 June 2020. 1 https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/C0751-visiting-healthcare- inpatient-settings-principles-131020_.pdf The number of visitors is limited to one close family contact or somebody important to the patient. However, where social distancing can be maintained throughout a visit, and where specific needs have been agreed with the clinical team, up to four visitors can be permitted. The previous guidance limited this to two visitors. For example, partners of women in labour; individuals receiving end-of-life care; and, where the visit is from a familiar carer (parent or guardian, supporter or personal assistant). Other people in attendance to support the needs of the patient (e.g. familiar carer, supporter or personal assistant) should not be counted as an additional visitor. Where face-to-face visits are not practical, virtual visits should be supported and facilitated. Visiting times may be staggered to accommodate visiting for all patients. For patients at the end of their life, the compassionate approach advised by this guidance is essential in balancing the importance of close family members and others important to the dying person, being able to spend precious time with them and say goodbye, with the need to manage infection risk and maintain the safety of the visitor(s), staff and other patients. Organisations should, in conjunction with the local incident team, use their own risk-based assessment to decide to what extent more relaxed visiting arrangements can be facilitated. NHS England advises that clinicians continue to seek out new and improved ways to maintain open communication with families and relatives of those who are in hospital. Locally, I am advised that the Stockport NHS Foundation Trust established a patient liaison team on 25 April 2020, which remains in place, to facilitate better communications with relatives. In relation to care homes, in April 2020, we published, Admissions to Care Homes guidance, co-branded with Public Health England, the Care Quality Commission (CQC) and NHS England. This set out advice on infection control procedures, for example, limiting visits to essential visits only, unless in exceptional circumstances, and providing advice on isolation, decontamination, cleaning and protective measures for staff. Following the publication of the Adult Social Care Winter Plan in September 2020, we published specific guidance on facilitating visits to care homes during the COVID-19 pandemic. This guidance enabled care homes to develop their own visiting policies based on a local dynamic risk assessment, taking a lead from their local Director of Public Health. On the introduction of Local Covid Alert Levels, we updated our guidance. This update enabled visiting to continue as previously for care homes in Local Covid Alert Level 1 (medium risk) but advised visits be limited to exceptional circumstances, such as end of life, in areas in Local Covid Alert Levels 2 and 3 (high and very high risk). On 1 December 2020, we published updated guidance to enable more meaningful indoor visits to take place for care home residents across all tiers. This was enabled by providing testing to visitors, following a successful pilot scheme. We began a roll-out of testing for visitors to all CQC-registered care homes in England, with a goal to have testing in place in all care homes by Christmas. In light of the introduction of Tier 4 restrictions on 20 December 2020, we published updated guidance which enabled visits to care homes in Tier 4 areas to continue to take place with arrangements such as outdoor visiting, substantial screens, visiting pods, or behind windows. Guidance for areas in Tiers 1-3 remained unchanged and continued to utilise testing to enable more meaningful indoor visits. Upon introduction of the national lockdown on 5 January 2020, we published updated guidance that expanded the Tier 4 visiting guidance, enabling the visits outlined above, nationally. Close-contact visits are not currently enabled. Visits in exceptional circumstances, such as end of life, should always be supported and enabled. We will be looking to ensure that a wider range of visiting arrangements are made available when it is safe to do so. We will publish updated guidance as this period of national lockdown ends. We recognise how important it is to allow care home residents to meet their loved ones safely, especially for those at the end of their lives. We appreciate the particular challenges visiting restrictions pose for people with dementia, people with learning disabilities and autistic adults, amongst others, as well as for their loved ones. All of our guidance enables care home providers, families and local professionals to work together to find the right balance between the benefits of visiting on wellbeing and quality of life, and the risk of transmission of COVID-19 to vulnerable residents and social care staff. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, MINISTER OF STATE FOR PATIENT SAFETY, SUICIDE PREVENTION AND MENTAL HEALTH NADINE DORRIES
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