Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2021-0004, written 10 Dec 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Dec 2020 |
|---|---|
| Reference | 2021-0004 |
| Deceased | Marion Glover |
| Coroner | Andrew Bridgman |
| Coroner area | Manchester South |
| Category | Care Home Health related deaths |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive Officer, Able Care & Support Services Ltd, Tameside Business Centre Enterprise Centre, Corporation Street, Hyde SK14 1AB. CORONER 1 am Andrew Bridgman, Assistant Coroner, for the coroner area of South Manchester CORONER'S LEGAL POWERS | 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 17.04.20 an investigation commenced inte the death of Marion Glover who died on 15.04.20. The investigation concluded on the 29.10.20 and the conclusion was one of Accident. The medical cause of death was 1a Bronchopneumonia 1b Urinary tract infection 1c 2 Alzheimer's disease/dementia, Parkinson's disease, Congestive Cardiac Failure, Facial & rib injuries CIRCUMSTANCES OF THE DEATH On the afternoon of 24.02.20 Mrs Glover suffered an unwitnessed fail in the entrance/foyer of Melbourne Court, where she had resided since May 2018. That afternoon she had been in the communal lounge area socialising following the ‘luncheon club’. Although Mrs Glover was able tc mobilise independently and did not need support per se, she was to be escorted back to her flat. When a care worker arrived to take Mrs Glover back to her flat she was no longer in the lounge area. Where Mrs Glover fell was not on any route back to her flat from the communal lounge. In the fall Mrs Glover sustained facial and rib fractures and was admitted to Tameside General Hospital, where it was determined that her injuries would be managed conservatively. Mrs Glover was discharged from Tameside GH to the Stamford (Rehabilitation) Unit on 06.03.20. On 15.04.20 Mrs Glover suffered a deterioration in her health and was admitted to Tameside General Hospital at around 21.00hrs, where she died iater that same day. CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. Residents at Melbourne Court lived independently within their own flats and that they are free to come and go as they wished, from their flats and from the building. That included those residents who were suffering from cognitive illnesses such as Alzheimer's or dementia, of which Mrs Glover was one. The entrance/exit door was not locked, other than overnight. During the course of her evidence Mrs Glover's daughter told me that on a number of occasions when she cafled to visit her mother she had come across other residents wandering in the corridors in a state of confusion, and who required assistance getting them back to the flats. Such scenarios as described were confirmed by the Senior Manager of Melbourne Court at the time of Mrs Glover's death, during the course of her evidence. As stated above Mrs Glover fell in the foyer area. This was not on route to her flat. The evidence suggested that Mrs Glover was starting to lose cognitive function and beginning to suffer confusion. We will never know but might she have been intending to go out. Had she done her absence would likely have gone unnoticed for some time. The MATTERS OF CONCERN are as follows. — On exploration of this issue, it became apparent that in the absence of any restriction on | residents leaving the building or observation of the foyer area there is a serious risk that such residents suffering cognitive illnesses/confusion can unknowingly leave the building. in the circumstances Melbourne Court does not appear to be suitable accommodation for residents who are suffering cognitive illnesses and confusion. 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. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 4" Feb 2020. |, 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely, | Mrs Glover’s daughter and to GHEE Lec! Services, Tameside MBC, 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 your response by the Chief Coroner. Ge Andrew Bridgman, Assistant Coroner i 10/12/2020
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.
Able Care & Support Services Ltd This response is provided by Y1 Capital Ltd who acquired Able Care and Support Services Ltd on 1st July 2021. Though the incident happened prior to the acquisition of Able Care and Support Services, we recognise our responsibility for the need to implement measures in ensuring that present and future residents who are suffering cognitive illnesses and confusion are fully assessed for their suitability to reside at Melbourne Court. Partnership Working A range of joint working is already in evidence with Tameside Metropolitan Borough Council and other professional agencies relating to the admission process and continued residency at Melbourne Court including: • Continued development of shared processes in ensuring that all risks are fully assessed pre-admission to Melbourne Court to include cognitive illnesses and confusion. • Weekly meetings/telephone calls with Local Authority and Healthcare/Social Care professionals in supporting residents and their needs. • When need identified through care staff observations, alerts and monthly audits, Multi-Disciplinary meetings are held to support people to live as independently as possible at Melbourne Court taking into consideration their wellbeing, support needs, medical issues to include cognitive illnesses and confusion and if their environment is conducive for their tenancy to remain in place. • Extra care panel held every two weeks with Tameside Metropolitan Borough Council and all Extra Care providers within the Tameside area. The panel enables all providers of extra care to discuss voids and referrals to the scheme, concerns raised, activities and the sharing of best practice. ‘We Care Because You Matter’ Registered Office: Hyde Business Centre, 10a Corporation Street , Hyde, Cheshire, SK14 1AB Company Reg. No. 08408264 Able Care & Support Services Ltd Continued Development of Service Provision Able Care and Support Services have introduced new systems to include: • On-Care digital care management software enabling care staff to record care delivery and all interaction with residents. The system enables care staff to raise an alert with the office if they should have any concerns or issues associated with a resident they care for. The • office ensures that all alerts are promptly dealt with, linked information recorded on On-Care in how the raised alert has been actioned, measures put in place, and progress in resolving issues raised. • EMAR (Electronic Medication Administration Record) software has been introduced allowing care staff to update MAR sheets • automatically and enabling the care office to have an accurate view of resident's medications in real time thus reducing medication errors. Introduction of Falls Managing report form. The form is to report all falls, whether witnessed or not, with follow up actions we have made in reducing/mitigating any further falls to the individual or other residents. • Scheduled annual reviews, or sooner should changes in the resident's needs be identified, of residents care and support plans with associated risk assessments to mitigate and further reduce risks to include those linked with cognitive illnesses, confusion and falls. Resulting actions required post review are recorded on Care Planner software and if identified, allied health professionals are contacted for advice and direction. Care and support plans are updated and shared with relevant care staff. ‘We Care Because You Matter’ Registered Office: Hyde Business Centre, 10a Corporation Street , Hyde, Cheshire, SK14 1AB Company Reg. No. 08408264 Able Care & Support Services Ltd Action By Whom By When December 2020 Able Care Management and TMBC Commissioning Team/Social Work Team Completion by Able Care staff. December 2020 Reviewed/actioned by Able Care office management Raised/logged by Able Care staff. Reviewed/actioned by Able Care office management. Able Care Office Management December 2020 December 2020 1 Collaborative working:- Enhanced Pre- admission risk assessment of new tenants Introduction of Falls Management Reporting Form 2 3 Alerts raised - Concerns/issues re residents 4 Scheduled annual review of resident’s needs (or sooner should changes in the resident’s need’s be identified). Progress Status (RAG) December 2020 Weekly meetings. Scheduled Multi- Disciplinary Meetings. In place December 2020 In place December 2020 In place December 2020 Evidence of completion Minutes of meetings. Completion of forms to include action taken. Recorded on Care-planner Alert with resulting action recorded on On- Care. Reviewed/revised support plan in place and recorded on Careplanner. ‘We Care Because You Matter’ Registered Office: Hyde Business Centre, 10a Corporation Street , Hyde, Cheshire, SK14 1AB Company Reg. No. 08408264
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