Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0274, written 17 Aug 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Aug 2021 |
|---|---|
| Reference | 2021-0274 |
| Deceased | Roland Stannard |
| Coroner | Nigel Parsley |
| Coroner area | Suffolk |
| 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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Rt Hon Savid Javid MP Secretary of State and Social Care Department of Health and Social Care 39 Victoria Street London SW1H 0EU 1 CORONER I am Nigel Parsley, Senior Coroner, for the coroner area of Suffolk. 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 5th March 2020 I commenced an investigation into the tragic death of Roland STANNARD The investigation concluded at the end of the inquest on 12th August 2021. The conclusion of the inquest was that:- Roland Stannard died as the result of a serious infection caused by a sacral sore. This sacral sore developed as a direct result of Roland being left on a commode chair overnight, on a background of changes to Roland’s medication regime which reduced his mobility and responsiveness. Being left seated for a protracted overnight period, unsupervised and without the required basic care, amounts to neglect. The medical cause of death was confirmed as: 1a Sepsis 1b Infected wounds from pressure sore 2 Frailty, Dementia 4 CIRCUMSTANCES OF THE DEATH Roland Stannard died at the West Suffolk Hospital on the 3rd October 2020. Mr Stannard had been admitted to the West Suffolk Hospital 24 days earlier, on the 9th September 2020 suffering from a serious pressure sore on his sacrum. This pressure sore had developed over the preceding weeks, whilst Mr Stannard was a resident at the Chiltern Meadows Care Home, Stowmarket in Suffolk, having been admitted there on the 25th June 2020. Mr Stannard was taking a drug (Nortriptyline) used to treat a long-term medical condition (vertigo migraines). This condition would make Mr Stannard suffer a number of symptoms including chronic head pain, low blood -pressure, loss of mobility and unresponsiveness. Due to miscommunication and miscoordination between the health care professionals and the staff caring for Mr Stannard, a lower than his usual dose was administered to him from the 25th June 2020. Again, due to miscommunication and miscoordination, this lower than usual dose was stopped completely on the 31st July 2020. Mr Stannard ’s lower than usual dose, then the removal of Nortriptyline, caused him to develop symptoms that masked his actual physical condition. On the evening and night on the 22nd to 23rd August 2020 Mr Stannard was left sitting on a commode chair overnight. In addition, Mr Stannard ’s 4-6 hour incontinence care was not carried out. Mr Stannard was sat on the commode chair for at least 13 hours, but possibly much longer. This triggered the development of a sacral sore. Mr Stannard ’s untreated vertigo migraine contributed to Mr Stannard remaining on the commode overnight. Once Mr Stannard ’s sacral sore had occurred, due to staff inexperience and lack of training, equipment provided to reduce the further development of the sore, was either not utilised, or if utilised, sometimes used incorrectly. The above factors led to Mr Stannard receiving sub-optimal care, allowing his serious sacral sore to develop. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters given 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 as follows. – In evidence it was heard that following this incident the Chiltern Meadows Care Home implemented a number of changes to policy, procedures and personnel. However, there is one area of concern which has wider implications which was not addressed. Specifically, once Mr Stannard’s sacral sore had occurred, due to staff inexperience and lack of training, the equipment provided to reduce the further development of his sacral sore was either not utilised, or if utilised sometimes used incorrectly. Residential homes, such as the one Mr Stannard was resident in, provide social and personal care, but medical treatment is provided by visiting medical professionals. In Mr Stannard’s case his nursing care was provided by visiting District Nursing staff. It was clear that once Mr Stannard had begun to develop a sacral sore, specialist equipment was made available by the District Nurses and provided within short timescales (in one instance the equipment identified as being needed, was delivered and fitted within a 4-hour period). This equipment included a high-grade air alternating mattress and an automatic lateral turning system. However, we were told in evidence that when a District Nurse next visited, the air bed was found to be set too high for someone of Mr Roland’s weight (and would therefore not be therapeutic as the bed would be too hard) and that the independent automatic lateral turning system had been unplugged. In relation to the unplugged device, the nurse was told that care staff were unsure of the correct mode of operation for this device so they had contacted the manufacturer and were erroneously told it could not be used in Mr Stannard’s circumstances. Both issues were identified and rectified when a District Nurse visited Mr Stannard at the home. However, the District Nurses did not necessarily visit every day and due to CoVID19 restrictions in place at the time, also provided online ‘virtual’ consultations. I am therefore concerned in relation to the provision of specialist equipment to any care home setting, in which the care home staff have insufficient knowledge and training on how to properly operate this specialist equipment. My concern is that in the absence of adequately trained staff, equipment designed to reduce the threat of developing pressure sores (or to aid the treatment of them), will continue to either not be used at all, or if used, used incorrectly. I am further concerned as to what point an assessment should be made to identify whether an individual needs nursing care, rather than continuing social care, and whether the provision of some types of complex medical equipment should prompt such an assessment. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken in order to prevent future deaths, and I believe you or your organisation have the power to take any such action you identify. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 12th October 2021 I, the Senior Coroner, may extend the period if I consider it reasonable to do so. 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;- 1. Mr Roland’s next of kin. 2. BUPA Chiltern Meadows Care Home, Stowmarket, Suffolk. Combs Ford Surgery, Bury St Edmunds, Suffolk. 3. Dr 4. Norfolk and Suffolk Foundation Trust. 5. East Suffolk and North Essex Foundation Trust. I am 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 Senior Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 17th August 2021 Nigel Parsley
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 Gillian Keegan MP Minister of State for Care and Mental Health 39 Victoria Street London SW1H 0EU 26 October 2021 Mr Nigel Parsley HM Senior Coroner, Suffolk HM Coroner's Office Beacon House 53-65 Whitehouse Road Ipswich IP1 5PB Dear Mr Parsley Thank you for your letter of 17 August 2021 to Sajid Javid about the death of Roland Stannard. I am replying as Minister with responsibility for adult social care and I am grateful for the additional time in which to do so. Firstly, I would like to say how saddened I was to read of the death of Mr Stannard. I can appreciate how deeply upsetting the circumstances of Mr Stannard’s death must be for his family and loved ones and I offer my most heartfelt condolences to them. In preparing this response, Departmental officials have made enquiries with NHS England and NHS Improvement (NHSEI) and the independent regulator for quality, the Care Quality Commission (the CQC). It is the responsibility of the CQC registered provider of care to make sure that staff have the skills, knowledge and experience to deliver safe, effective care that meets people’s needs. If, for example, a resident is at risk of pressure ulcers, the provider is required to ensure that the staff have the appropriate training to look after the person effectively. These responsibilities are set out in The Health and Social Care Act 2008 (Regulated activities) Regulations 2014 (particularly in this instance, regulations 12; 15 and 18)1. The CQC uses the information it holds about a service to plan what it looks at in an inspection. The CQC would not always look in detail at staff training in the use of a specific piece of equipment. However, if the CQC had received information which suggests concerns in this area, or its observations on inspection indicate an issue with staff training, the CQC would follow this up, speaking with staff and the registered manager, as well as sampling training records. Should the CQC identify shortfalls, it would apply its normal decision-making processes to determine the appropriate regulatory or enforcement response. This would depend on the circumstances and the seriousness of the concerns. 1 The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (legislation.gov.uk) I am advised that the CQC conducted an inspection of Chilton Meadows Care Home in March 2021, the report of which is published on the CQC’s website2. The Care Home was rated ‘Inadequate’ and is now in special measures, being monitored closely by the CQC to ensure improvements are made or that the appropriate regulatory action is taken if this is not the case. In relation to your concern about the point at which an assessment of nursing care needs should be made, it may be helpful to note that how and when a person should be assessed for NHS-Funded Nursing Care and NHS Continuing Healthcare is explained in the National Framework3, published in 2018. It is the responsibility of the relevant clinical commissioning group (CCG) to ensure that an assessment for NHS-Funded Nursing Care is carried out where it appears that a person may have a need for nursing care and that eligibility for NHS Continuing Healthcare is considered prior to any decision on eligibility for NHS-Funded Nursing Care. NHS-Funded Nursing Care is the funding provided by the NHS to nursing homes to support the provision of nursing care for those assessed as eligible. An individual is eligible for NHS-Funded Nursing Care if they have been assessed and it has been determined that they have a need for care from a registered nurse, and that their overall needs would be most appropriately met in a care home with nursing. CCGs should work closely with their local partners and develop agreed protocols so that individuals can be referred via the appropriate local process to arrange for an assessment of needs for health and social care to be undertaken. The East Suffolk and North Essex NHS Foundation Trust has advised that the prescribing of specialist equipment, such as pressure relieving devices, would not normally trigger the need for a nursing needs assessment as this equipment is commonplace in community and residential care settings. Community nurses visiting patients would check at each visit the appropriateness and use of the equipment and if concerned, would make a safeguarding referral. A nursing needs assessment is more likely to be triggered by other factors such as a significant deterioration in the patient’s condition or complex care needs. The NHS Continuing Healthcare Checklist, published in 20184, is a tool which can be used to help identify individuals who may require a full assessment of eligibility for NHS Continuing Healthcare. You explain in your report that district nurses did not attend the Chiltern Meadows Care Home on a daily basis and because of measures relating to the Covid-19 pandemic, consultations were sometimes conducted online. You may wish to note that the Framework for Enhanced Health in Care Homes5 is used as guidance for visiting professionals. This means that a clinical decision will have been made regarding the 2 Chilton Meadows Care Home (cqc.org.uk) 3 National framework for NHS continuing healthcare and NHS-funded nursing care - GOV.UK (www.gov.uk). 4 NHS continuing healthcare checklist - GOV.UK (www.gov.uk) 5 the-framework-for-enhanced-health-in-care-homes-v2-0.pdf (england.nhs.uk) frequency of in-person visits to Mr Stannard. There is nothing in the Enhanced Health in Care Homes Framework that would restrict visiting healthcare professionals, including district nurses, from undertaking important appointments in care homes. On 1 May 2020, NHSEI wrote to all CCGs, GPs, and community services providers requesting that clinical support for care homes be put in place as a priority, including the delivery of weekly ‘check ins’ and the establishment of a named clinical lead for each care home. The latest NHS clinical support offer was outlined in the Adult Social Care Winter Plan on 18 September 20206. Throughout the pandemic, the NHS has extended support to the social care sector and ensured close working across health and social care. The support offer includes, but is not limited to, support for care homes and social care through primary care and community services and the rollout of the Enhanced Health in Care Homes model7, which includes professional leadership and expert advice on infection prevention and control where needed, and testing before discharge from hospital to a care home. The Enhanced Health in Care Homes service requires Primary Care Networks to be aligned with care homes in their area, with care homes having a named clinical lead and, from 1 October 2020: to deliver a weekly home round for care home residents prioritised for review; make use of multidisciplinary teams to develop and refresh personalised care and support plans; and, support a patient’s discharge from hospital and transfers of care between settings. Finally, it is vitally important that local organisations and system-level leaders reflect carefully on, and take learnings from, the circumstances of deaths related to the Covid-19 pandemic, such as that of Mr Stannard, and I am grateful to you for bringing these concerns to my attention. It is right that there is an active and continuous process of learning, adapting and responding to the challenges of the Covid-19 pandemic and you will know that the Prime Minister has announced that there will be a full statutory inquiry into the Government’s response to the Covid-19 pandemic, beginning in Spring 2022, to identify national learnings. I hope this response is helpful. GILLIAN KEEGAN 6 Adult social care: our COVID-19 winter plan 2020 to 2021 - GOV.UK (www.gov.uk) 7 NHS England » Enhanced Health in Care Homes Framework
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