Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0122, written 10 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 | 10 Feb 2021 |
|---|---|
| Reference | 2021-0122 |
| Deceased | Eric Bird |
| Coroner | Joanne Lees |
| Coroner area | Black Country |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Castlehill Specialist Care Centre 2. CQC 1 CORONER I am Mrs Joanne Lees, Area Coroner for the coroner area of The Black Country. 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 11/12/20 I commenced an investigation into the death of Eric Harold Bird. The investigation concluded at the end of the inquest on 9/2/21. The inquest found and recorded the following facts; On the evening of 21/11/20 the deceased, a 91-year-old gentleman suffered a fall at the care home where he was residing. Mr Bird suffered with vascular dementia and was assessed as being at high risk of falls. He was independently mobile and had a history of recent falls resulting in bruising to his person and was taking apixaban. He suffered with hypertension, atrial fibrillation and frailty. On 21/11/20 he was seen by a member of staff to fall between two sofas and fall backwards from a standing position hitting his head on the ground as he fell. An ambulance was called, and he was taken to hospital later than evening where he was found to have sustained a subdural haematoma which was managed conservatively. He sadly passed away in hospital on 30/11/20. The medical cause of death was established as; 1a) Subdural Haematoma 1b) Fall 2) Hypertension, Atrial Fibrillation, Dementia, Frailty The Coroner’s conclusion was one of Accident 4 CIRCUMSTANCES OF THE DEATH On 20/10/20 the deceased, a 91-year-old gentleman suffering with Dementia was admitted to Castlehill specialist care centre. On admission, a falls risk assessment was undertaken where the deceased scored as being at high risk of falls. I heard in evidence that the care home put in place two measures to address this risk; 1) a member of staff to be present in communal areas at all times observing residents and 2) an acoustic monitoring alarm system in Mr Bird’s bedroom. It was understood that a high/low bed was standard in the home. Mr Bird was described as being independently mobile and needed no additional walking aids. He was taking lorazepam which may have increased his level of agitation and thereby his risk of falls. He required 24 hour care for his own safety. The court heard in evidence that between Mr Bird’s admission on 20/10/20 and 21/11/20 inclusive, he suffered seven falls in a 4-week period whilst a resident at Castlehill. Five of those falls were unwitnessed. Four of those falls took 1 place whilst Mr Bird was in the bedroom and the fifth in a nursing station. Two falls were witnessed and took place in the communal areas of the unit where Mr Bird was placed. Three of the seven falls resulted in Mr Bird hitting his head. The latter fall on 21/11/20 resulted in a subdural haematoma which led directly to the death of Mr Bird. I also heard evidence that there had been a change of management at the home and that there had been a recent inspection by the CQC but I was unaware of the outcome. 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – 1. After Mr Bird’s admission and initial falls risk assessment, there was a reference that Mr Bird needed to be referred to the physio team but no evidence this was actually done; 2. The inquest heard that Castlehill polices had not been followed after each fall whereby Mr Bird had hit his head. Mr Bird was taking apixaban which meant he was at a higher risk of bleeding. Evidence was heard that policy required 999 to be called. This was not done on 1/11/20 nor on 14/11/20. 3. On 21/11/20 the nurse on duty called 111 instead of following policy to call 999; 4. On 21/11/20 I heard evidence that the fall occurred at approximately 20.20/20.30 hours. Records suggested the 111 service was contacted at 21.06. I heard evidence that it was the 111 service that made arrangements for an ambulance to attend and the EPR showed that the ambulance was contacted at 21.34 arriving on site at 21.47; 5. On arrival the ambulance was unable to gain access to the care home until 22.11 as there was no answer at the door. I heard evidence at the inquest that arrangements had now been made for a staff member to wait in the reception area when an ambulance is now called out of hours to facilitate entry; 6. There was no evidence that Mr Bird’s falls risk assessment and falls care plan had been updated after every fall; 7. There was no evidence of any changes being made to Mr Birds falls care plan after the fall on 14/11/20 and no rationale recorded for not doing so; 8. I heard evidence that after the fall on 21/11/20 whereby Mr Bird was taken to hospital, that senior management who were off site were not contacted for over 2 hours after Mr Bird fell; 9. There were discrepancies in the recording of the falls on the monthly accidents and incidents form and no evidence that any consideration had been given to a pattern of falls which needed to be addressed to reduce Mr Bird’s apparent increasing risks. 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. 2 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report (9/4/21), namely by 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 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 10/2/21 Mrs Joanne M. Lees 3
2 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.
HSCA Further Information Citygate Gallowgate Newcastle upon Tyne NE1 4PA Telephone: Fax: 03000 616171 Mrs. Joanne M. Lees Area Coroner The Black Country Jurisdiction Coroners Court, Jack Judge House, Halesowen Street, Oldbury, B69 2AJ 06 April 2021 Care Quality Commission Our Reference: Dear HM Coroner Prevention of future death report following inquest into the death of Mr Eric Harold Bird. Thank you for sending CQC a copy of the prevention of future death report issued following the death of Mr Eric Harold Bird. We note the legal requirement upon Castlehill Specialist Care Centre and the Care Quality Commission to respond to your report within 56 days. The provider location registered with CQC is located at 390 Chester Road, Walsall, WS9 9DE and is part of the Walsall Clinical Commissioning Group. The provider is registered for the following regulated activities: Accommodation for persons who require nursing or personal care Treatment of disease, disorder or injury The CQC was notified of Mr Bird’s death on 09 December 2020 by West Midlands Police. West Midlands Police informed the CQC they did not feel there was anything criminal to investigate and were closing the case. The CQC contacted Castlehill Specialist Care Centre as a statutory notification had not been received. There had been a delay from Castlehill Specialist Care Centre in sending the notification due to Mr Bird passing away in hospital. Castlehill Specialist Care Centre notified the CQC of the death on 11 January 2021. An inspection had already been prompted following whistleblowing concern in relation to restraint, deprivation of liberty safeguards, staffing levels and falls 1 management. A large-scale safeguarding investigation (LSI) meeting was held on 18 December 2020, where inspector subsequently closed on 25 January 2021 as an outcome the local authority quality team were asked to provide ongoing support in relation to falls management. We also noted the content of the LSI and used this to support our future planning of inspection. The inspection process would assess any likely future risks. attended. The LSI was The provider was inspected by CQC on 19 January 2021 in the form of a comprehensive inspection which assessed five domains; Safe, Effective, Caring, responsive and Well Led. No enforcement action has been proposed as a result of this inspection. The provider received the draft report on 22 March 2021. As part of the report publishing process, the Provider is then given the opportunity to review the draft report before it is finalised. If the Provider believes there are any factual inaccuracies in the report these can be submitted to the CQC and will be considered before the final report is published. The matters of concern which arose from the preventing future deaths report have prompted the CQC to take action. In direct response, we held a management review meeting on 17 February 2021. Following the management review meeting, we reviewed the evidence we held about Castlehill Specialist Care Centre, the information held following the specific incident review related to Mr Bird’s death and information following the inspection completed in January 2021. Our findings and actions are outlined as follows: On 09 December 2020 we began to request and review the information we had following Mr Bird’s fall and death in line with our specific incident guidance. So far, we have found the following: • We reviewed the care plan and risk assessment Castlehill Specialist Care Centre had implemented in relation to Mr Birds falls risks. Mr Bird had been identified as a high falls risk but was able to mobilise independently. • Castlehill Specialist Care Centre had implemented care plans and risk assessments for staff to support Mr Bird with falls management. There was no mention of what action staff should take if Mr Bird sustained a head injury. However, on the fall that subsequently led to Mr Birds death, staff did seek medical intervention. • Castlehill Specialist Care centre have confirmed there was no referral made to physiotherapy during Mr Birds stay between 20 October 2020 and 21 November 2020. • Castlehill Specialist Care Centre told us they had not identified blood thinners as a risk as part of their medicines policy. They told us the lesson learnt would be to put a statement in their medication policy that this type of medication group thins the blood. 2 • As a result of these findings, CQC held a management review meeting on 18 March 2021 to discuss the findings under our specific incident guidance. In order to open a formal criminal investigation, we have to be able to evidence a Registered Person (either a Registered Provider or Registered Manager) failed to provide safe care and treatment to Mr Bird in relation to this incident and can prove beyond reasonable doubt this incident was avoidable. We did not feel that this threshold was met and therefore will not progress the case. As a result of the findings an inspection was carried out on 19 January 2021. The inspection found the following: • Care plans and risk assessments record updates have been made following falls and contain details of the falls. Reviews in care plans indicate a frequency of more than monthly and reviews have been done as and when care needs changed, or contact was made with health professionals. • Review sections in care plans have been updated as and when contact has been made with external professionals. • Where service users’ medicines may cause drowsiness and increase risk of falls, this is identified in care plans and risk assessments. Medical advice has been sought for service user when their needs have changed, for medicines to be reviewed. • Analysis of trends in incidents and accidents across the home occurred to determine whether any further action could be taken to mitigate risks to people. • There were systems in place to review incidents and accidents on an individual basis to reduce the chance of a similar incident occurring again. • Following analysis, a referral to the local falls team has been made for one service users. In addition, night monitoring had been changed for another person. There were details of where staffing levels had changing to meet peoples need. • There had been falls recorded where no injuries were sustained so therefore no medical attention needed. Care plans stated that staff should monitor every four hours for 24 hours following a fall. • The operations manager carried out a monthly quality assurance tool where falls management was checked. This tool would identify if any patterns or trends of falls had not been addressed. There were no concerns identified in the quality assurance tool. • Records showed healthcare professionals had been involved for other healthcare conditions, for example occupational therapy and tissue viability nurses. The service acted appropriately to changes in healthcare needs. The GP was conducting twice weekly ward rounds via Zoom. • There were many good aspects of monitoring within the service such as audits on safeguarding, activities and wellbeing and Benzodiazepine usage. Where improvements were needed, an action plan was put in place and followed up. 3 • On the day of inspection when the inspector arrived on site a person had fallen, and an ambulance was present. The manager was analysing what could be done to prevent reoccurrence and we had a discussion where the manager said they do not wait until the end of the month to review incidents/accidents but do this as and when they occur. We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner. Finally, please include the reference number any further information from us. Thank you in advance for your assistance. Yours sincerely if you require CQC Inspection Manager 4
Regulation 28: Report to prevent Further Deaths Castlehill Specialist Care Centre confirm the following actions have been taken: We have fitted extra assistive technology in the form of individual door sensors to every bedroom to alert staff to residents’ movement. This is in addition to the acoustic monitoring system that was already in place in each bedroom. In order to aid timely access to the building we have fitted several new monitoring screens throughout the corridors linked to the external door bell with an audible alert. We will continue to make 111/999 calls following any fall and will call 999 whenever a resident falls who is prescribed Apixaban. This will continue despite some concern from the Local Authority that we are availing of these services too often. Upon any fall we continue to raise safeguarding alerts and will request 1:1 funding to maintain the resident’s safety whilst further assessments take place where appropriate. This funding is often declined and in that eventuality we we will review the suitability of the placement. We have improved access to a very good Occupational Therapist with whom we have an excellent working relationship. Unfortunately due to the level of cognitive impairment of a number of our residents there is often little prospect of meaningful rehabilitation but we are grateful of the support and continue to refer. EB had previously been assessed by Physiotherapy and Occupational Health in hospital and due to his dementia diagnosis and severe cognitive impairment he was sadly deemed as not being suitable for rehabilitation. We have a weekly ward round with the GP are our Senior nursing team where all information including multi-disciplinary referrals are discussed and appropriate referrals are made by the GP. Director of Operations
See every Prevention of Future Deaths report matching Care Home Health related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.