Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0138, written 5 May 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 May 2021 |
|---|---|
| Reference | 2021-0138 |
| Deceased | Stephen MAGUIRE |
| Coroner | Adam Hodson |
| Coroner area | Birmingham and Solihull |
| 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
THIS REPORT IS BEING SENT TO:
Limited
CORONER
- Manager of Options for Care
I am Adam Hodson, Assistant Coroner for Birmingham and Solihull districts.
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.
INVESTIGATION and INQUEST
On 21 September 2020 I commenced an investigation into the death of Stephen Anthony
MAGUIRE. The investigation concluded at the end of the inquest on 27 April 2021 . The
conclusion of the inquest was that Mr Stephen Anthony MAGUIRE died due to an accident.
CIRCUMSTANCES OF THE DEATH
Mr Stephen Anthony MAGUIRE was detained at Dartmouth House 70-72 Handsworth Wood
Road, Handsworth Road, Birmingham (run by Options for Care Limited) pursuant to s.3 Mental
Health Act 1983 for treatment of chronic treatment resistant paranoid schizophrenia. At lunchtime
on 14/09/2020, Mr Stephen Anthony MAGUIRE was in the lounge area with other residents where
he was seen to be about to start eating his lunch, when he got up from the table, walked a short
distance and then collapsed. Staff began CPR whilst an ambulance was summoned, and it was
noted his chest was not rising with ventilation. He had a difficult anatomy due to a large tongue
and adipose neck, and upon examination using laryngoscope, paramedics reported that his airway
presented as a Cormack-Lehane grade 4 view. Multiple and repeated efforts were attempted to
troubleshoot and clear his airway in accordance with Joint Royal College Ambulance Liaison
Committee Guidelines. A period of roughly 30 minutes passed where he was without oxygen
before video laryngoscope revealed a mass of chewed meat at the base of his tongue deep in his
larynx. Despite the obstruction being removed with forceps and resuscitation being continued, he
was deemed to have sustained an unsurvivable brain injury due to suffering 30 minutes of
absolute hypoxia. Treatment was stopped, and he died at 13:40 on 14/09/2020.
Following a post mortem, the medical cause of death was determined to be:
1a CHOKING
1b
1c
II
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. –
1. I heard evidence that the PIT alarm used by staff member,
, did
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not work when pressed. I heard evidence this was alarm was checked after the
incident and found to not have been charged. I heard evidence from
that Options for Care Limited have a system whereby it is the night staffs’
responsibility to check and charge the PIT alarms overnight, and it is the
responsibility of the day care staff to check that their PIT alarms are charged and
operational when they come on shift in the morning ("the charging system").
Somehow, this charging system failed. Although not causative in Mr Stephen Anthony
MAGUIRE's inquest, if a member of staff is unable to utilise their own PIT alarm in an
emergency, this creates an obvious risk of death to both service users and staff alike.
2. I heard evidence that
was an agency worker working for Options
for Care at the time of Mr Stephen Anthony MAGUIRE's death, and there was a
suspicion (but which could not be proven) that they may have either been unaware
of the charging system, or made a simple error. Although not causative in Mr Stephen
Anthony MAGUIRE's death, if members of staff (both full time and agency workers alike)
are unaware of the charging policy, or are not trained and reminded in the same, there is
the risk of death if a member of staff is unable to utilise their own PIT alarm in an
emergency due to the same not being charged.
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. You should:
1. consider how the charging system can be enhanced and strengthened to ensure that staff are
provided with properly functioning and charged PIT alarms for their use at the commencement of
their shift;
2. consider how and whether additional training/refresher training can be provided to staff - both
full time and agency alike - to ensure awareness and compliance with the charging system.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by
30/06/2021. I, the coroner, may extend the period.
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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.
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
1.
(Next of Kin)
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2. West Midlands Ambulance Service
I have also sent it to the CQC who may find it useful or of interest.
I 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.
5 May 2021
9
Signature: Adam Hodson
Assistant Coroner for Birmingham and Solihull
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.
70 – 72 Handsworth Wood Road
Handsworth Wood, Birmingham, B20 2DT
Mr A. Hodson
Assistant Coroner for Birmingham and Solihull Districts
Sent Via email
Dear Mr Hodson,
CQC Registered Manager
Dartmouth House
23 June 2021
Please see below my response to the regulation 28 report to prevent future deaths received 05 May
2021. This responds to the actions which should be taken identified in the report:
1. Consider how the charging system can be enhanced and strengthened to ensure that staff
are provided with properly functioning and charged PIT alarms for their use at the
commencement of their shift;
2. Consider how and whether additional training/ refresher training can be provided to staff –
both full time and agency alike – to ensure awareness and compliance with the charging
system.
Dartmouth House has instituted an operational change with the introduction of a ‘security lead’ role.
This is allocated to an appropriately experienced clinical staff member on commencement of each
shift.
The security lead is responsible for:
• Checking PIT alarms at the beginning of each shift and ensuring they are working correctly.
• Handing out PIT alarms and keys and recording to whom they have been allocated.
•
Identifying any malfunctioning PIT alarms and removing the PIT from circulation and
reporting this to a member of the management team or the unit administrator and
replacing this with a functioning PIT alarm.
• Ensuring and documenting the return of keys and PIT alarms and placing PIT alarms on
charge before handing over to the next security lead.
Options for Care has an existing system of Review and Feedback (supervision) sessions for clinical
staff each facilitated by an appropriate line manager. To strengthen existing systems and processes,
the management team will utilise these sessions to:
• Share with staff how to report an issue with any PIT alarms to the appropriate party (the
management team or unit administrator) to facilitate repair or replacement.
• Explain how to access spare PIT alarms for replacement.
• Explain and reinforce the roles and responsibilities of the allocated security lead role.
• Check staff are aware of how to test a PIT alarm and determine whether it is functioning
correctly.
Agency or temporary staff will:
• Receive training on how to effectively test and use the PIT alarms on first attendance at the
service.
70 – 72 Handsworth Wood Road
Handsworth Wood, Birmingham, B20 2DT
• Receive an update on how to test and use the PIT alarm on each subsequent visit to the
service, aided by the security lead for that shift.
These actions and changes will be further reinforced through staff meetings.
I trust these changes already in place at Dartmouth House effectively meet the requirements of the
actions which should be taken as identified in the Regulation 28 report. Should you require any
further information or clarification, please do not hesitate to contact me.
Yours sincerely,
Dartmouth House Registered Manager
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