Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0030, written 5 Feb 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 Feb 2021 |
|---|---|
| Reference | 2021-0030 |
| Deceased | Joseph O’Neill |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| 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: Prevention of Future Deaths report
Joseph O’NEILL (died 12.08.20)
THIS REPORT IS BEING SENT TO:
1.
Managing Director
Care Outlook Limited
260 Stanstead Road
Sydenham
London SE23 1DD
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 20 August 2020, I commenced an investigation into the death of
Joseph O’Neill, aged 88 years. The investigation concluded at the end of
the inquest earlier today. I made a narrative determination, a copy of
which I attach.
4
CIRCUMSTANCES OF THE DEATH
Mr O’Neill developed bronchopneumonia, suffered heat stroke, then
became dehydrated and died.
If he had been properly hydrated and had been in an appropriately cool
environment, he would not have died when he did.
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.
Mr O’Neill was attended by carers from Care Outlook four times a day.
It was noted that he was very hot and he was brought a fan. He was also
offered respite care in a care home. However, he was fearful of catching
COVID19 and in 2020 care home COVID death rates were very high.
When Mr O’Neill refused a place in a care home, the Care Outlook staff
did not do anything to resolve the fault with Mr O’Neill’s heating, so it
remained on in the middle of a heatwave. An engineer was called to fix
his door hinge, but not his heating. Mr O’Neill desperately needed a
reduction in the temperature of his flat, first and foremost by the heating
being fixed, but Care Outlook staff did not deal with this.
He also needed immediate rehydration. When he was admitted to
hospital, he was in deficit by about three litres. He was offered a drink
by care staff at mealtimes, but he needed constant prompting and
encouragement to drink enough. His deterioration was not recognised.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that 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 5 April 2020. 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 following.
2
niece of Joseph O’Neill
Hackney Borough Council
Care Quality Commission for England
HHJ Thomas Teague QC, the Chief Coroner of England & Wales
I am also under a duty to send a copy of your response to the Chief
Coroner and all interested persons who in my opinion should receive it.
I may also send a copy of your response to any other person who I
believe 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
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.
9
DATE SIGNED BY SENIOR CORONER
05.02.21 ME Hassell
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.
Care Outlook
2-10 Laurel Grove,
Sydenham, London
SE26 4JY
Tel:
info@careoutlook.co.uk
www.careoutlook.co.uk
By Email and Post:
Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
Email:
18th April 2021
Dear Madam
Inquest into the death of Joseph O’Neil (died 12.08.20)
I write further to the report issued under Regulation 28 of the Coroners (Investigations) Regulations
2013 and to outline the action that has been taken by Care Outlook since the inquest into the death
of Joseph O’Neil.
1. Since the incident Care Outlook has introduced a digital care planning and monitoring system;
People Planner. The system allows care plans to be accessed by staff on a mobile handset and
to record the care delivered in real time. The system has a reporting facility whereby staff are
able to complete and submit a report on their handset which is then flagged up on the system
and email received by the office in real time.
The system has been successfully introduced and is in use by all staff. This will ensure that any
concerns raised by staff are recorded immediately and that a permanent record will always be
retained. The system also ensure that those concerns are highlighted immediately to care
managers.
2. We have also introduced a “Cause for Concern” form for staff to complete, to guide care staff
in relation to the types of incident or concern that need to be raised. We are currently
working to ensure that the form can be included in the electronic reports on People Planner.
3. All staff in Hackney are being re-trained in the Recording and Reporting of incidents. Initial
guidance has been issued in the form of a PowerPoint presentation that has been circulated to
all staff. The training outlines the importance of reporting all concerns and ensuring that clear
and comprehensive records are made. The training also covers the responsibilities of
supervisors and managers to ensure that any concerns raised are resolved and or reported to
appropriate third parties (including medical professionals, emergency services, commissioners
and safeguarding authorities).
Care Outlook Ltd. Reg. address: 2-10 Laurel Grove, London, SE26 4JY. Corporation. No. 5302971
We are working to ensure this training can also be delivered as part of our formal e-learning
package. Our training lead is preparing an introduction to the training and a supporting
competency test, which will form part of our formal induction process.
The initial training has been sent to all staff, including care workers, office / field-based
supervisors and managers.
4. We have also prepared a factsheet providing enhanced guidance for care workers in relation
to the risks of dehydration. The factsheet contains practical guidance on how to spot the signs
of dehydration, the routine action that can be taken by care workers to prevent this and the
urgent action that must be taken when a client is at risk. The fact sheet has been provided to
all care workers.
I hope that this information is of assistance but if you have any questions then please do not hesitate to
contact me.
Yours Sincerely,
Managing Director
Care Outlook Ltd. Reg. address: 2-10 Laurel Grove, London, SE26 4JY. Corporation. No. 5302971
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