Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0230, written 7 Jul 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Jul 2021 |
|---|---|
| Reference | 2021-0230 |
| Deceased | Dorothy Seekings |
| Coroner | Sean McGovern |
| Coroner area | Warwickshire |
| 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: – Owner-Clifton Court Nursing Home (Crosscrown Ltd) 1. 2. Family of Mrs. Dorothy Seekings 3. Chief Coroner 4. Care Quality Commission 1 CORONER I am Sean McGovern, senior coroner, for the coroner area of Warwickshire 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. [HYPERLINKS] 3 INVESTIGATION and INQUEST On 21st September 2019, I commenced an investigation into the death of Dorothy Seekings 87 years old. The investigation concluded at the end of the inquest on 7th July 2021.The conclusion of the inquest was a Narrative Verdict. 4 CIRCUMSTANCES OF THE DEATH Mrs Seekings was resident at Clifton Court Nursing Home in Rugby. She was a frail elderly lady who could neither speak nor walk. She was highly vulnerable. During the night of 8th August 2019 another resident of the home entered her room. It is not clear why he went into her room but he suffered from dementia and may have thought he was in his room which was next door. A carer entered Mrs Seeking’s room at approximately 4.00am and discovered she was dead. Lying next to her on bed was the other resident who was fully clothed. A post mortem examination showed she had died of blunt force injuries. On the balance of probabilities those injuries were caused by the other resident. He was arrested that night but was assessed as being unfit to be detained or interviewed. Subsequently he was detained under Mental Health Act. I am satisfied that he was suffering from rapidly deteriorating Vascular Dementia and on 8th August 2019 could not form the mens rea for any form of unlawful killing. He died on 5 May 2020. Although the events of 8th August 2019 were not reasonably predictable I 1 record that there was ineffective promulgation of the care plan for the other resident and occasions of physical violence to care and nursing staff (but not to fellow residents) by the other resident largely around his personal care (washing, bathing), which were missed opportunities to trigger a re- assessment of his overall risk 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. – did not record incidents had acted aggressively to staff members (1) the care plans for where including an occasion when a staff member was kicked in the mouth by (2) the failure to raise a safeguarding alert with the local authority regarding the above incident. (3) The staff did not appear to be aware of the contents of the care plan for resident ACTION SHOULD BE TAKEN . or other 6 In my opinion action should be taken to prevent future deaths and I believe 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, 2 namely by 2nd September 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons (daughters). I have also sent it to the Care Quality Commission who may find it useful or of interest. & 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 7th July 2021 Sean McGovern 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.
RESPONSE TO CORONER’S REQUEST FOR REGULATION 28 REPORT TO PREVENT FUTURE DEATHS FOLLOWING THE INQUEST INTO THE DEATH OF DOROTHY SEEKINGS CONCLUDED ON THE 7TH JULY 2021 BY A NARRATIVE VERDICT MATTERS OF CONCERN The matters of concern raised by the Coroner are as follows: (i) The care plans for did not record incidents where had acted aggressively to staff members including an occasion when a staff member was kicked in the mouth by . (ii) The failure to raise a safeguarding alert with the Local Authority regarding the above incident. (iii) The staff did not appear to be aware of the contents of the care plan for or other residents. Crosscrown Limited owns a number of Residential & Nursing Care Homes in Warwickshire, Dorset and Wiltshire and offer a range of services from residential and nursing care through to dementia and respite care. Following the tragic events of the 8th August 2019 the organisation has implemented a number of changes which are now in place and which hopefully address the concerns which have been raised. The two key changes are the acceleration of the implementation of a digital care management software system called CareDocs. This was being gradually introduced into the Homes run by Crosscrown during the Summer of 2019 but the events of August 8th accelerated the implementation of the new system and it is now in place in all Crosscrown Homes including Clifton Court and has been for some time. The digital CareDocs system allows Care Plans to be created that meet the specific requirements of individual service users and it allows the creation of a care plan reflective of the needs and preferences of the individual user. The CareDocs system is stored on a cloud portal package and mobile devices which are connected to the internet allow detailed daily notes to be recorded, care assessments to take place and for all staff to review resident information. Clifton Court have found the system intuitive and easy to use by all staff regardless of their level of computer literacy. The evidence based features of the system allow Clifton Court to demonstrate a safe, caring and responsive environment and allows compliance to be monitored. It allows for the creation of a digital care plan, digital care assessments, daily notes to be updated and charts and body maps to all be recorded and in one place. The staff can have easy access to profiles and most importantly the digital care document itself through desk top computers, laptops, tablets and even mobile phones. Clifton Court has purchased a number of tablets to be given to each member of staff for their use and that is the usual device upon which information is recorded. It should be stressed that all nurses and carers have access to CareDocs. When a new member of staff joins the organisation they undergo a two week period of training for which time they are supernumerary and thereafter there is a “buddy” scheme which lasts from between two weeks and three months depending on the requirements of the individual member of staff. During that time the individual undergoes a detailed period of training into the CareDocs system. The introduction of the system was dependent on upgrading the Wi-fi capability throughout the Homes which ensures that the electronic care plan records can be utilised and read and updated throughout Clifton Court. The second significant change made by Crosscrown Limited was the appointment of a Quality Assurance & Compliance Manager in August 2019 which led to the creation of an Operations Team developed throughout 2020 and fully implemented by December 2020. This team is responsible for compliance and governance across the Crosscrown Homes including of course Clifton Court. The team contains three members who are responsible for Quality Assurance and Compliance together with matters of governance, human resources and learning and development. The Operations Team are supported and guided by an independent external consultant called The Care Excellence Partnership. The lead at that organisation is an experienced former national lead and inspector of services for the CQC. The Operations Team have overseen the implementation of the CareDocs scheme and implemented a number of new processes which deal with issues of training and good practice. The Operations Team have implemented two relevant programs entitled “Understanding Challenging Behaviour and Dementia Training” and “Safeguarding Training” and the issue of safeguarding is now a part of the induction process at the Crosscrown Homes. The Operations Team has implemented an enhanced agenda for the fortnightly staff meetings that are held at Clifton Court to include inter alia infection control – Covid, health and safety and accurate and systematic recording of behavioral issues. Under the new scheme such behaviour is recorded on the CareDocs system which prompts the completion of an Antecedent Behaviour Consequences form on the CareDocs system. The Care Home Manager at Clifton Court checks on a daily basis for amongst other things any ABC charts which may have been completed by members of staff. Should any safeguarding issues be recorded then the Manager will contact Adult Social Services and complete that process. The Operations Team are copied into all emails in relation to any safeguarding issues. In the last eighteen months Clifton Court has made eight referrals to the Adult Social Services Team at Warwickshire County Council all of which were closed down without an action by the Council. The issue of safeguarding is also now part of the Monthly Managers Report and is analysed by the Operations Team and evaluated for any patterns or learning issues. The Operations Team has implemented backing up the issue of safeguarding by issuing each and every member of staff with a small pocket sized laminated safeguarding document to remind the staff of safeguarding issues.
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