Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0003, written 5 Jan 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Jan 2021 |
|---|---|
| Reference | 2021-0003 |
| Deceased | Arthur Johnson |
| Coroner | Jason Pegg |
| Coroner area | Hampshire, Portsmouth and Southampton |
| Category | Care Home Health 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 CORONER 1 Hampshire County Council, Adult Services 2 Manager Oakridge House Residential Home I am Jason PEGG, Area Coroner for the area of Hampshire, Portsmouth and Southampton 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 21st April 2020 I commenced an investigation into the death of Arthur Edward JOHNSON aged 85. The investigation concluded at the end of the inquest on 5th January 2021. The conclusion of the inquest was: Accident The Medical Cause of Death was: I a Intracerebral Haemorrhage I b Fall I c II Spontaneous intracranial haemorrhage, Hypertension, Alzheimer's Disease 4 CIRCUMSTANCES OF THE DEATH The deceased died on 20th April 2020 at the Royal Hampshire County Hospital, Winchester, Hampshire. The deceased suffered an unwitnessed fall on 17th April 2020 at Oakridge House Residential Home in consequence of which the deceased suffered a head injury and intracerebral haemorrhage. The deceased had also suffered a spontaneous intracranial haemorrhage which contributed to the death of the deceased. 5 CORONER’S CONCERNS The MATTERS OF CONCERNS are as follows: Oakridge House Residential Home is staffed by non-medically trained personnel. The “Post-Falls” process/policy direct that 999/111 should be called when a head injury is suspected. The evidence at inquest indicated that where a head injury was considered a possibility 999/111 was not called. My concern is that the present process does not give adequate direction, provide sufficient clarity nor distinguish between “possible” and “suspected” head injury. It is not clear when 999/111 should be called. Further, I have concerns in relation to the training provided to assist Residential Home staff in the recognition of intracranial injury. 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 02 March 2021. 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. (Spouse). 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 Jason PEGG Area Coroner for Hampshire, Portsmouth and Southampton Dated: 05 January 2021
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.
Jason Pegg
Area Coroner for Hampshire,
Portsmouth and Southampton
Castle Hill, The Castle,
Winchester, SO23 8UL
E n q u i r i e s t o
D i r e c t l i n e
D a t e
23 February 2021
Dear Mr Pegg,
A d u l t s ’ H e a l t h a n d C a r e
3 r d F l o o r , E l i z a b e t h I I C o u r t W e s t
S u s s e x S t r e e t
W i n c h e s t e r
H a m p s h i r e S O 2 3 8 U Q
T e l e p h o n e
T e l e p h o n e
F a x 0 1 9 6 2 8 4 7 6 8 1
M y r e f e r e n c e
Y o u r r e f e r e n c e
E - m a i l
Report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and
regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 dated 5
January 2021 in connection with the investigation into the death of Arthur Edward
JOHNSON.
Further to the above report of the inquest concluding “accident” and medical cause of
intracerebral haemorrhage, I have noted your concerns relating to the response by staff at
Oakridge House Residential Home and perceived shortcomings in the management of falls
and suspected head injury.
I have now had the opportunity to follow up the matter further and am able to provide
additional information that may not have been previously presented during your
investigation, for which I apologise.
I understand that when you requested the documentation for Mr Johnson’s inquest, you
received only part of the current “falls protocol”. As a result of your recommendations the
entire protocol has been reviewed and updated in line with current NICE guidance. This
clearly directs staff to contact 999 or 111. The revised protocol is attached and I trust
addresses the concern relating to the clarity of practice guidance.
Regarding staff training, previously staff were trained in how to respond to head injury
events during our “Emergency Aid” course. Following your comments, this has been
reviewed. Although staff working in a residential setting are not clinically trained, they will
now be required to participate in a standalone learning module designed specifically to
focus on falls management issues, including risk of head injury. This will compliment other
practice guidance for example risk assessment and risk management plans for mobile
elderly people in a communal living setting.
D i r e c t o r o f A d u l t s ’ H e a l t h a n d C a r e
I apologise again that you were not provided with all the relevant information at the time of
your initial request. I trust this letter will reassure you that the matter has been taken
seriously and as a result revised guidance and training arrangements established.
Yours sincerely
Director of Adults’ Health and Care
cc:
, Registered Manager, Oakridge House
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