Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0239, written 16 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 | 16 Nov 2020 |
|---|---|
| Reference | 2020-0239 |
| Deceased | Jean Williams |
| Coroner | Rachel Galloway |
| Coroner area | Manchester (West) |
| Category | Care Home Health related deaths · Product related deaths |
| Organisation named | Blackpool Teaching Hospitals NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
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: (1) CEO - NHS England (2) CEO - Blackpool Teaching Hospitals NHS Foundation Trust (3) CEO - Lancashire County Council (4) Managing Director – Mobility 2000 1 CORONER I am, Rachel Galloway, Assistant Coroner, for the Coroner Area of Lancashire & Blackburn with Darwen. 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 the 15th January 2018 an investigation was commenced into the death of Jean Williams, aged 80, born 24th August 1937. The investigation concluded at the end of a 5-day Inquest (without a Jury) on the 9th November 2020. The Medical Cause of Death was: 1a Hanging My Conclusion at the inquest was: Accident contributed to by neglect. 4 CIRCUMSTANCES OF THE DEATH 1. Jean Williams was 80 years of age at the time of her death on the 19th November 2017. At the time of her death, Jean Williams was temporarily resident at Thornton House Care Home (“the Home”) in Thornton-Cleveleys. At 8.27 am on the 19th November 2017, Jean Williams was found deceased by day care staff at the Home in her room (Room A10). She was found to be fully clothed, lying on top of her duvet and an unplugged bed sensor. Her head had become trapped between the side of her bed and the chest of drawers, with her neck resting upon the bar of the bed lever, causing her death. On the evidence, I found she would have become unconscious within a matter of seconds; her death was rapid. 2. The Bed Lever had been prescribed by the Occupational Therapy Team at the Blackpool Teaching Hospitals NHS Foundation Trust (“the Trust”). On the evidence, I found that it had been fitted to Jean Williams’ bed (by a member of 1 the Occupational Therapy Team at the Trust) on the 3rd November 2017. The Bed Lever had a strap riveted to its frame. However, the Lever was not secured to Jean Williams’ bed with that strap. The purpose of the strap was to prevent the Bed Lever from becoming dislodged and moving away from the edge of the bed, causing a risk of entrapment. Despite this, the Trust training of the Occupational Therapy Team in 2017 was that the use of the strap was optional. 3. Jean Williams’ death occurred at some time between the hours of 6.30 a.m. and 8.27 a.m. on the 19th November 2017. Her death occurred because the strap attached to the Bed Lever had not been used to secure the bed lever to the divan bed. Had it been so secured, she would not have died on the 19th November 2017. 5 CORONER’S CONCERNS During 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. During the inquest, evidence was heard that: The supplier of the Bed Lever (Mobility 2000), Occupational Therapy staff at the Trust and Lancashire County Council Staff (including Care Assistants) working at Thornton House now fit or adjust Bed Levers if – on assessment – there is identified to be a problem. This raised concerns due to the following: (a) Mobility 2000 and Lancashire County Council staff are fitting Bed Levers and/or adjusting Bed Levers in the absence of the patient (and therefore not taking into account important individual patient factors such as patient height, when fitting the Lever). (b) Lancashire County Council do not currently have in place a policy that any concerns/issues raised on their risk assessments of bed levers at the premises should be reported to the Occupational Therapy Team at the Trust. (c) The Occupational Therapy Team at the Trust, who are now correctly trained to fit and assess a patient for the use of the Bed Lever, are not – at present – routinely fitting the bed levers at Thornton House. In fact, there has been a miscommunication that Bed Levers are no longer to be used at Thornton House. Occupational Therapists prescribe bed levers due to the medical need of the patient and are now trained to fit them properly following full assessment of the patient. I am concerned that the above raises a risk of future deaths in that bed levers are being fitted in the absence of the patient and not by the fully trained experts who have prescribed them. In addition, the following matters in respect of Mobility 2000 specifically caused concern: (a) Mobility 2000 did and do continue to fit bed levers in the absence of the patient at various different locations (not just at Thornton House) (b) I found that Mobility 2000 did not routinely use the strap when fitting bed levers in 2017 and it is unclear whether staff now have training that they should always use a strap on a Divan bed (c) The evidence from the Director of Mobility 2000 was that no Bed Levers had been supplied without a strap (to his knowledge). It was clear on the evidence 2 that Mobility 2000 had purchased Bed Levers without a strap from Drive Devilbiss Healthcare Limited (“Drive”), which should only be used with a specialist bed (and not a Divan bed, which always requires a strap). There is a risk that Mobility 2000 are supplying or fitting these bed levers (Model 130) without a strap to Divan beds. I have also addressed this report to NHS England, as it was unclear on the evidence whether there may be similar instances of not using straps for Bed Levers (on Divan Beds) by Occupational Therapy Teams at other NHS Trusts. 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 14th January 2021. I, the assistant 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: (1) (the son of Jean Williams) (2) Blackpool Teaching Hospital NHS Foundation Trust (3) Lancashire County Council (4) Mobility 2000 Limited (5) Mr (6) Ms (7) Ms (8) Ms (9) Drive Devilbiss Healthcare Limited 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 Assistant Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Dated 16TH NOVEMBER 2020 Signed: Rachel Galloway HM Assistant Coroner Manchester West 3
3 responses 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.
INHS) Blackpool Teaching Hospitals NHS Foundation Trust Trust Headquarters Blackpool Victona Hospital Whinney Heys Road Blackpool Lancashire FY3 8NR Tel Email 16 December 2020 Mrs Rachel Galloway HM Assistant Coroner, Manchester West Coroner Area of Lancashire & Blackburn with Darwen E , Manchester City Coroners Office and Court @ E I V [E Exchange Floor 2 The Royal Exchange Building 1 Cross Street DEC 2028 Manchester M2 7EF senenen.., ee i, me Dear Mrs Galloway Re Jean Williams - inquest concluded 9 November 2020 | write to you confirming receipt of your Regulation 28 Report to Prevent Future Deaths, dated 16 November 2020, in relation to the death of Jean Williams, who sadly passed away on 19 November 2017 | would like to extend my sincere condolences to Mrs Williams’ family In your letter you explain that during the inquest, the evidence revealed matters giving rise to concern and that in your opinion there ts a risk that future deaths will occur unless action is taken We have taken your concerns extremely seriously and we have carefully considered the concerns applicable to Blackpool Teaching Hospitals For those concerns, we have taken the following actions 1) Lancashire County Council do not currently have in place a policy that any concerns/issues raised on their risk assessments of bed levers at the premises should be reported to the Occupational Therapy Team at the Trust. And 2) The Occupational Therapy Team at the Trust, who are now correctly trained to fit and assess a patient for the use of the Bed Lever, are not — at present — routinely fitting the bed levers at Thornton House. In fact, there has been a miscommunication that Bed Levers are no longer to be used at Thornton House. Occupational Therapists prescribe bed levers due to the medical need of the patient and are now trained to fit them properly following full assessment of the patient. RESEARCH MATTERS AND SAVES LIVES - TODAY’S RESEARCH IS TOMORROW'S CARE Blackpool Teaching Hospitals 1s a Centre of Clinical and Research Excellence providing quality up to date care We are actively involved in undertaking research to Improve treatment of our patients A member of the healthcare team may discuss current clinical trials with you (32 disability y @8G3 confident a aa EMPLOYER NHS] Blackpool Teaching Hospitals NHS Foundation Trust Although these concerns are not necessarily directed at Blackpool Teaching Hospitals, we were very keen to support our colleagues from Lancashire County Council (LCC) in making services for patients safer and a meeting was held between our Trust and LCC on 2 December 2020 to address the concerns raised. In summary, the following agreements were made a) Bed levers are permitted for use at Thornton House An individual risk assessment must be completed by the prescriber for each patient, in line with Blackpool Teaching Hospital's cross- prescriber training b) The ‘deliver and fit’ model will no longer be used for the provision of bed levers at Thornton House Prescribers will request delivery only and the bed lever wit! be fitted by the prescriber and the ‘check visit’ completed in the presence of the patient. Should a patient bring their own bed lever into Thornton House, the therapy staff with complete a risk assessment to ensure it Is fit for purpose and safe for use, prior to the bed lever being utilised The intermediate care team have been made aware of the above decisions at the meeting on 2 December 2020 c) LCC have advised that following the inquest, the Thornton House daily risk assessment was updated and now specifies that the bed lever should be removed if any concerns are identified within daily checks The individual identifying the concern is responsible for removing the bed lever from use and contacting the Intermediate Care Team, to request a review by the prescriber The patient’s care plan is then to be updated to reflect the removal of the bed lever and identify any increased support required to meet the patient’s needs. In addition to completion of our interal action plan, which was part of the evidence submission for the inquest, and in order to drive wider professional learning, the Trust's Interim Chief AHP has also shared the findings of this very sad event, and your overall conclusions, with senior Allied Health Professions (AHP) Leads across the Lancashire and South Cumbria Integrated Care System, at the monthly AHP Council meeting This will encourage system learning amongst senior AHP colleagues from different trusts across the Lancashire and South Cumbria Integrated Care System, who will undoubtedly introduce learning and improvements in their respective trusts where appropriate to do so. 1 hope that the above responses provide you with the assurance that we have taken your concerns extremely seriously and that we have taken appropriate actions to address your concerns, in order to prevent a similar event from occurring Yours sincerely Dr Executive Medical Director
FOA of the Coroner, Ms Galloway Via By email: , Coroners Officer Phone: Email: Your ref: Our ref: Date: 14 January 2021 Dear Ms Galloway, Jean Williams – Inquest 3rd Nov – 9th Nov 2020 Further to your Regulation 28 report of 16th Nov 2020, I write with confirmation of actions taken by Lancashire County Council (LCC). The safety of service users is of the utmost importance for LCC. We take your finding that there were matters giving rise to concern and your opinion that there was a risk that future deaths may occur extremely seriously. A meeting was held between relevant staff members at LCC and Blackpool Teaching Hospitals (BTH) on 2nd December 2020, both parties agreeing the need to work together to address the concerns. The Council confirms the following actions in addressing your concerns:-. a) Mobility 2000 and Lancashire County Council staff are fitting Bed Levers and/or adjusting Bed Levers in the absence of the patient (and therefore not taking into account important individual patient factors such as patient height, when fitting the Lever). The Occupational Therapist is responsible for the assessment of need for a bed lever which is undertaken with input from individual service users and considering their individual needs. The therapist will complete a prescription to the retailer on a deliver only basis. Only a trained member of the Occupational Therapy team can fit the bed lever and only with the service user present, to ensure it is relevant to their individual need. Risk assessments are undertaken at this time by both Occupational Therapy staff and LCC staff and support plans are updated to reflect the use of the bed lever. Following the installation of the bed lever LCC staff check it is correctly positioned twice each day. Should it have significantly moved position the bed lever is removed until a time when a trained member of the Occupational Therapy team can refit it. This process is detailed in the updated LCC document titled OP103 Bed Rails and Bed Levers Policy and Procedure, which governs the process and to which staff are trained. LCC staff will also ensure that new bed lever deliveries are not fitted until a trained member of the Occupational Therapy team is able to fit them. Lancashire County Council, PO Box 100, County Hall, Preston, PR1 0LD Neither Mobility 2000 nor any other retailer will fit any bed levers. These new arrangements were implemented week commencing 7th December 2020. b) Lancashire County Council do not currently have in place a policy that any concerns/issues raised on their risk assessments of bed levers at the premises should be reported to the Occupational Therapy Team at the Trust. Following the hearing immediate action was taken to give guidance to staff on the escalation process. Our 'Bed Rail and Bed Lever Policy and Procedure' was already in place but that has now been updated, as referred to above, to make clear how concerns should be escalated and which staff/colleagues are to be made aware. This updated document is live as of 08 January 2021 and a further review will take place in April 2021 to ensure it is clear to all staff and has been appropriately implemented. c) The Occupational Therapy Team at the Trust, who are now correctly trained to fit and assess a patient for the use of the Bed Lever, are not – at present – routinely fitting the bed In fact, there has been a miscommunication that Bed Levers are no longer to be used at Thornton House. Occupational Therapists prescribe bed levers due to the medical need of the patient and are now trained to fit them properly following full assessment of the patient. levers at Thornton House. The miscommunication that suggested that bed levers are not used at Thornton House has been rectified and an agreement between LCC and BTH has been reached that bed levers can be used when appropriate to the resident's needs. As outlined at (a) above, further agreement was made that bed levers would be prescribed on a 'deliver only' basis and only fitted by a trained member of the Occupational Therapy team. Further to the points raised, with regard to the incident at Thornton House, LCC have implemented the updated policies at all 16 LCC operated older peoples residential homes. I trust the information and confirmation of action detailed in this letter give you the assurances required that suitable action has taken place to rectify your concerns. Yours sincerely Director of Adults Disability and Care Services Enc: OP103 Bed Rails and Bed Levers Policy and Procedure
RESPONSE FROM MOBILITY 2000 LTD - JEAN WILLIAMS INQUEST With regard to the fitting of bed levers in the absence of the patient this is likely to be because, on occasion, the equipment needs to be in place prior to the release of a patient from hospital. As the prescriptions are issued by LCC we will await their instruction of any changes to the current system. Our staff have always fitted the strap when installing the bed levers and they will continue to do so. We do occasionally purchase bed levers without a strap as some of our retail customers prefer them and they are still passed by the medical devices agency; however, these are not, and will not, be supplied via the tces system as the specification does not allow it. We have recently carried out further training with our staff on how to fit the levers and straps according to the manufacturer's instructions. Further action taken is to make sure a hard copy of the manufacturer's instructions is supplied with every bed lever. We await instructions from LCC with any change of policy regarding the timing of fitting the bed levers, since the incident involving Jean Williams. Finally, it should be noted that even in cases where Mobility 2000 Ltd have installed a bed lever we have no control of what happens to it once we have left the property. We know from past experience that the levers are often taken off beds for a number of reasons and subsequently replaced by someone other than ourselves.
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