Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0178, written 14 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 | 14 Apr 2021 |
|---|---|
| Reference | 2021-0178 |
| Deceased | Amy Chiverall |
| Coroner | Joanne Kearsley |
| Coroner area | Manchester North |
| 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 (1) | REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1._Rochcare 75-77 Drake Street, Rochdale O| . 1 CORONER 1am Joanne Kearsley, Senior Coroner for the Coroner area of Manchester North 2 | CoRONER’s LEGAL POWERS 4 ! make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and Regulations 28. and 29 of the Coroners (Investigations) Regulations 2013 3 INVESTIGATION and INQUEST | On the 9" July 2020 | commenced an investigation into the death of Mrs Amy Chiverall | 4 CIRCUMSTANCES OF DEATH Mrs Chiverall was a resident of Royley House Care Home, Lea View, Royton. On the 1% July 2020 she had an unwitnessed fall in her room. The Court heard evidence she was a moderate risk of falls. Her call bell (which are fixed items) was in her room but not within her reach. Her fall is likely to have occurred some 1-2 hours before she was found. Medical attention was not sought in a timely manner and post fall observations were not conducted in line with the Care home policy. When she was admitted to hospital on the evening of the 2 July 2020 she was found to have multiple rib fractures and a traumatic pneumothorax. Mrs Chiverall died on the 34% July 2020. 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:- The Court heard the home do not use pendant call alarms. This was described as a business decision. The Home has 18 residents of mixed falls risk but less than half would be of a moderate or high risk of falls. The Court was concerned that for those residents a fixed call bell may not be of assistance, as in this case, as it would be out of reach when required. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe each of you respectively 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 10/07/2021. |, 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:- The family of Mrs Chiverall 1am 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 from. He may send a copy of this report to any person who he believes may find it usefulor of interest. You may make representations to | me the coroner at the time of your response, about the-selease or the publication of your response by the Chief Coroner. [9 | Date: JH “Ld 0 QA . ; Signe
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.
Hello Since this lady death, as @ company wre have reviewed 2 number of processes, including: Staff record keeping. They have since had record keeping training. ‘The process of ensuring staff know and understand policies has changed Flash meetings include incidents that have occurred, and what being followed us. ‘The current manager has record keeping and post falls information at the forefront of the day. Thsincludes a folder teed Fas prevention project. thas elevant assessments all equipment, care needs and checks (Carevsion] along with falls policy, post falls too! Infra-red call points nave been installed in 10.oFthe 15 roamsin use. The inte-red points allow people to have the call bell attached tothe person, not tothe wall. For those people who do mobilise independently and have capacity, but are at risk of falls; they can wear the call bellto suramon help when required. Chair alarm calls have been ordered, ths are similar to bed alarms that sound when someone stand up. Please let me know ifyou have any other queries in relation to this, arn always happy to help. Kind Regards, ‘A; Roche House, 79/77 Drake Street, Rochdale, Lancs, OL16 188
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