Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0110, written 15 Apr 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Apr 2021 |
|---|---|
| Reference | 2021-0110 |
| Deceased | Ailsa Stewart |
| Coroner | Chris Morris |
| Coroner area | Manchester South |
| Category | Community health care · Other 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: Rt. Hon. Matt Hancock, Secretary of State for Health and Social Care. 1 | CORONER | am Chris Morris, Area Coroner for Manchester South. 2 | 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. http:/Awww.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 3rd December 2019, Christopher Briggs, Assistant Coroner, opened an inquest into the death of Ailsa Stewart who died on ist May 2019 aged 62 years. The investigation concluded at the end of the inquest which | heard between 6" and 9th April 2021. A post mortem examination undertaken by Dr | Consultant Pathologist on the Home Office Register, determined that Ms Stewart died as a consequence of: 1.a) Sepsis; due to 1.b) Pneumonia, pyelonephritis, limb ischaemia, pressure ulcers and epithelial damage due to prolonged contact with urine. 2) Obesity, Type II Diabetes. By way of conclusion, | recorded that Ms Stewart died as a consequence of natural causes, contributed to by neglect. 4 | CIRCUMSTANCES OF THE DEATH Ms Stewart was bed-bound as a consequence of obesity, and suffered with Type II diabetes. She lived alone and was essentially dependant on domiciliary carers for all care. On 16th April 2019, carers asked a GP to visit Ms Stewart as they were concerned she was unwell. Following an examination, the GP sent Ms Stewart to hospital for further assessment and possible treatment. As a consequence, Ms Stewart's care provider suspended her package having assumed she would be admitted to hospital without verifying this was the case. Ms Stewart was assessed in the Emergency Department and following tests, was not considered to be acutely unwell. On the Morning of 17th | April 2019, she was deemed medically fit to return home and transport was arranged via the ambulance service on the basis that her care package remained in place. An ambulance crew left Ms Stewart in bed at her home on that day, understanding that carers would be arriving to attend to her shortly. | On 29th April 2019, the same ambulance crew retumed to Ms Stewart's home to transport her to a pre-arranged medical appointment whereupon they found her to be gravely ill in her bed. She was taken to hospital where she subsequently died. Because her care package had been suspended, Ms Stewart received no domiciliary care between 17th and 29th April 2019. This lack of care caused her death. | 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 court heard evidence as to an extensive range of actions which local | agencies have taken in response to Ms Stewart's death to try and reduce the risk of a similar set of circumstances occurring again. That said, it was clear from the evidence that in England, family members play an essential part in ensuring continuity of care is maintained by sharing information between different agencies, and facilitating the co-ordination of care provided to vulnerable patients, particularly in circumstances where unplanned hospital attendances are required. It is a matter of concer that no cohesive national framework or guidance exists across health and social care, to prescribe the circumstances in which a domiciliary care package can be suspended, or sets out specific rules as to the roles and responsibilities of particular agencies to convey information when a vulnerable patient is sent home from an urgent care setting without having formally been admitted. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action. Af YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 10th June 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 N fant COPIES and PUBLICATION sent a copy to f the Medical Defence Union who represented the General Practitioner, (in-house solicitor) who represented Stockport Metropolitan Borough Council, EEE of Browne Jacobson LLP who represented Stockport NHS Foundation Trust, and Taner of Weightmans LLP who represented North West Ambulance Service NHS Trust. | 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. | have sent a copy of my report to the Chief Coroner and Sa arr who had °C been related to Ms Stewart by marriage. | also have t | Dated: 15th April 2021 —D SS Signature: Wienke, LZ_— Chris Morris Aréa Cordrier, Manchest ; Cae
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 Helen Whately MP Minister of State for Care 39 Victoria Street London SW1H 0EU 08 June 2021 Mr Christopher Morris HM Area Coroner, Manchester South HM Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG Dear Mr Morris, Thank you for your letter of 15 April 2021 about the death of Ailsa Stewart. I am replying as the Minister with responsibility for adult social care. Firstly, I wish to offer my condolences to Ms Stewart’s family and loved ones. High quality, safe care is a priority for all and I was extremely saddened to learn of the circumstances surrounding Ms Stewart’s death. I have noted carefully your concerns about the roles and responsibilities of health and care agencies in conveying information when a vulnerable patient is sent home from an urgent care setting; and the circumstances in which a domiciliary care package can be suspended. In preparing this response, my officials have made enquiries with NHS England and NHS Improvement (NHSE and NHSI) and their regional and local partners. Safeguarding is everyone’s business and it is of concern that there was an insufficient multi-agency approach in place to safeguard Ms Stewart. The Care Act 20141 specifies that local authorities and their relevant partners have a reciprocal responsibility to cooperate to promote the wellbeing of adults with care and support needs. All involved parties across health and social care should work together to agree whether it is appropriate to suspend care. Home care providers need to assess the risks posed by a reduction or suspension of visits and take prompt reparative action, recognising that people living alone may be particularly vulnerable if care visits are missed or suspended. 1 Care Act 2014 (legislation.gov.uk) During the pandemic the Government published guidance2 for home care providers which covers hospital discharge and other matters. We aim to continue to provide guidance to the sector post-pandemic. As mentioned earlier, my officials have also sought information from NHS England and NHS Improvement (NHSE and NHSI) with regards to the circumstances surrounding Ms Stewart’s care. NHSE and NHSI has assured my officials that it is extremely rare for a care package to be automatically stopped by the care provider. The Care Act statutory guidance highlights the importance of partnership and cooperation in the prevention of abuse or neglect. The Act requires a local authority to set up a Safeguarding Adults Board, with authority to carry out a Safeguarding Adult Review (SAR) when serious harm or a fatality has occurred. The aim of the SAR should be to promote effective learning and improvement action across all relevant organisations, to prevent future deaths or serious harm occurring again. NHSE and NHSI have informed my department that it is conventional operational practice in Stockport that when a person in receipt of a community care package attends the hospital Emergency Department for assessment, that this package remains in place. The care provider has given assurances that this had been the case on previous occasions, consistent with local agreements. My officials have been informed that the care provider accepted that, on this occasion, it was a breach of the agreed plan and contractual arrangements for Stockport Adult Social Services. NHSE and NHSI have informed my officials that technically Ms Stewart had not been admitted to hospital and it was therefore not necessary for the Trust to invoke their discharge process. My officials have been informed that Stockport NHS Trust will continue to work as part of shared care arrangements in line with national standards and the protection of vulnerable people. This will ensure when a patient attends for an assessment, a care package in the community will remain in place until notification that the patient requires admission into an inpatient provision. Following Ms Stewart’s death the Trust shared an additional safety alert on 9th May 2019 to alert practitioners to this potential risk and give due consideration to the vulnerability of the patient, their medical presentation and what should happen when returning home. The Safety Alert states “it is the responsibility of the nursing staff to take reasonable steps to ensure the carers are aware of the discharge. This must be documented in the patient’s medical records”. 2 Coronavirus (COVID-19): provision of home care - GOV.UK (www.gov.uk). North West Ambulance Services (NWAS) has since introduced an additional question to prevent a journey from proceeding until confirmation is received, at the point of discharge booking, that a care package is either not required or is in place. In addition, communications have been sent to all NWAS and third-party resources reminding them of their obligation to ensure patients are taken to their destination and left with access to a communication device or an alarm raising facility. Promoting integrated care is a priority for this Government. There is a traditional divide between primary care, community services and hospitals, and social care services. The differences in commissioning, incentives and accountability have all contributed to creating barriers to seamless delivery of person-centred care. Our aim is to join up care around a person’s needs so that, from their perspective, the experience of care is seamless. We want everyone to be supported to live their best lives. We are confident that our proposals in the Health and Care White Paper3, such as Integrated Care Systems, will help to address the barriers which prevent effective join-up between health and social care services and support local systems to implement solutions that work best for them. This integrated approach to person-centred care will bring together actors in health and social care, alongside local and voluntary partners, to support people to retain their independence, health and wellbeing for longer. I hope this response is helpful. Thank you for bringing these concerns to my attention. HELEN WHATELY 3 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/960548/integrat ion-and-innovation-working-together-to-improve-health-and-social-care-for-all-web-version.pdf
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