Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0283, written 24 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 | 24 Aug 2021 |
|---|---|
| Reference | 2021-0283 |
| Deceased | Peter Harte |
| 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: 1) CORONER -MANAGER OF BROMFORD LANE NURSING HOME I am Mr Adam Hodson, Assistant Coroner for Birmingham and Solihull 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 29 March 2021 I commenced an investigation into the death of Peter Michael HARTE. The investigation concluded at the end of the inquest. The conclusion of the inquest was Natural Causes. The deceased was admitted into Birmingham Heartlands Hospital at 01:27 on 19/03/2021 and was diagnosed and treated for sepsis. His prognosis was poor due to his pre-existing comorbidities and it was determined that a ward-based ceiling of care was appropriate and would preserve his dignity. Sadly, his condition deteriorated despite treatment, and he died with his family at his bedside at 10:25 on 19/03/2021. Prior to admission, he was being cared for in a care home but he was difficult to manage and was non-compliant with care due to symptoms of suspected vascular dementia. During that time, his skin was monitored, but records were not kept between 14th to 18th March. Post-mortem examination revealed pressure ulcers to his buttocks and sacral area, but these occurred peri-mortem and did not cause or contribute to death. His death was due to multiple organ failure and sepsis, stemming from a bacterial skin infection causing cellulitis which sadly did not respond to treatment. CIRCUMSTANCES OF THE DEATH Natural Causes Following a post mortem, the medical cause of death was determined to be: 1a Multi-organ failure / septic shock 1b Staphylococcus Aureus Septicaemia 1c Cellulitis II Vascular insufficiency due to atherosclerosis 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. The evidence of suggested that proper skin inspections and skin 1 2 3 4 5 monitoring were not carried out between 14th to 18th March 2021 as, had they had been carried out, they would have been documented and recorded in detailed body maps. 2. The evidence of suggests that skin inspections were carried out but were not recorded. It was admitted by proper and adequate records by staff. in evidence that there was a failure to keep 3. At inquest I found that, on the balance of probabilities, inspections were carried out but observations were not recorded and records were not kept. 4. It was unclear whether this was a "one-off" incident or whether it reflected a systemic issue. On reflection, the fact that records were not taken or kept over a period of four consecutive days (as opposed to one isolated day), is indicative of a systemic issue that staff are not ensuring that their observations are correctly and adequately recorded. 5. It is clear that a failure to ensure that there is a correctly working system of record taking poses a risk of future deaths occurring, especially in the context of extremely frail and vulnerable adults/residents who in a position of dependency by virtue of their frailty or vulnerability. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 19 October 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Next of Kin 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. 24 August 2021 6 7 8 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.
Bromford lane care centre RE Peter Heart 18/10/2021 Dear Sir, This is a response to some concerns raised by the coroner following an investigation into a death of one of our service users Mr Peter Harte. Firstly, I think it is imperative to remember that the service user in question had extreme behaviours that challenges, and the care plans can evidence the actions needed to try and de-escalate and overcome the service users’ distress and agitation. When the service user moved into the service, he was under one of our enablement beds. This is a bed that enables multi-disciplinary team members to assess, collate and facilitate care and identify necessary treatment for illness etc. The service user was showing challenging behaviour where he was aggressive, agitated and obviously distressed by the situation and the environment, this usually calms after a couple of days as people with dementia are unable to cope with changes in their environment, although this was not the case with peter. The staff who looked after this service user had all the relevant experience and training to facilitate and identify techniques to reduce distress. The service user would not settle in their bed and would spend almost all of the day and night on the floor. Crash mats was therefore put in place. We see this sort of behaviour often in our environment and client group that we look after. In Peters case he found the floor comforting and preferred to remain on the floor. when trying to encourage peter to go to bed this heightened his agitation. That being said, this service user was still provided with all the necessary care, support, and empathy throughout their stay in the service. The nursing staff and care team identified potential concerns with his health and flagged these up to the relevant MDT members for treatment and assessment, this included both the GP and the mental health team to offer the service user and staff support to try and overcome/resolve the service user’s challenging behaviours and agitation. When peter was admitted to Bromford lane there were numerous wounds bruise on his body. Throughout the service users stay and on admission the staff had completed mandatory body maps for multiple bruises, scars, scabs etc all at various stages of healing, these can be identified on the body maps shared to the coroner. This in itself was a challenging task as the service user was often non-compliant with many aspects of his care and treatment and would show behaviour that challenges by being aggressive towards staff. He was also mostly on the floor meaning that staff would try and discreetly and check skin integrity to try and reduce this service users’ distress and maintain their privacy and dignity. (We often discreetly check skin for many service users who are non-compliant, this is often done in the service user best interests and on occasions can be extremely difficult to complete accurately due to lashing out or the service user not able to keep still). When we say discreetly, we would have to try and gain inspection of peters body when doing personal care dealing with his incontinent needs and although some areas of his body were mapped on discussion with staff that delivered care to peter they found it extremely difficult due to peter lashing out at them. The staff who was looking after the peter on the days in question have explained that the peter was distressed, and they had done everything they could to reduce his distress and both nursing and care staff had tried to complete body maps however had been unsuccessful for some of the pre-existing wounds. However, the body maps for the 16/3/2021 18/3/21 had been completed where possible by the staff on the 15/3/21 and 17/3/2021 peter was non-compliant all day when staff approached peter, he bit punched and slapped them. so interventions were limited due to peters agitation but observations still took place. In the evidence pack provided to the coroner ABC charts was in place on both these days as peter was uncompliant with personnel care on both days. All staff have been spoken to and have received feedback and support to follow paperwork protocol if unable to follow Bromford lane care centre RE Peter Heart 18/10/2021 process. Documentation needs to be put in place. After coroner’s court I sat back and reflected on what was said and discussed with staff who had nursed peter, they felt they had provided good care to peter but found it very difficult to provide personnel care due to his behaviours. So throughout the days they ensured he received care in his best interest his personnel care, eating drinking and incontinent needs, which took many attempts on every occasion but our staff continued to ensure his well being and keep his dignity. Staff fully understand the importance of body maps and why we do them, but due to the difficult circumstance with peters challenging behaviour staff felt they couldn’t do anymore for peter than they already had. Following this review, we have had an external auditor come and audit our body maps to ensure that they are being completed accurately for all service users . This identified that we are completing body maps in a timely manner and that staff are aware of the importance of skin integrity, how to check for concerns and how to report any concerns to the relevant staff member. I think it is essential to understand that at Bromford lane we pride ourselves on ensuring that the most complex service user group are supported with all aspects of their care. This can in itself provide us with some challenges we as a team feel we are very responsive to the service user’s well- being and any concerns or changes are reported to the relevant MDT member to ensure we have all the support needed to offer the best quality of life for the most complex client group. We have a very good rapport with the local services and they often express that they feel we absolutely do thing as needed to provide best care and sometimes this is in the most extreme circumstances. We will of course continue to monitor the service quality and identify areas of improvement required and ensure that the staff are offered suitable training and ongoing supervision and support as required. Many thanks Home manager Bromford lane care centre RE Peter Heart 18/10/2021 The staff who was looking after the service user on the days in question have explained that the service user was distressed, and they had done everything they could to reduce his distress and both nursing and care staff had tried to complete body maps however had been unsuccessful for some of the pre-existing wounds. However, the body mas had been completed where possible by the staff. All staff have been spoken to and have received feedback and support to improve the service provided Following this review, we have had an external auditor come and audit our body maps to ensure that they are being completed accurately. This identified that we are completing body maps in a timely manner and that staff are aware of the importance of skin integrity, how to check for concerns and how to report any concerns to the relevant staff member. I think it is essential to understand that at Bromford lane we pride ourselves on ensuring that the most complex service user group are supported with all aspects of their care. This can in itself provide us with some challenges we as a team feel we are very responsive to the service user’s well- being and any concerns or changes are reported to the relevant MDT member to ensure we have all the support needed to offer the best quality of life for the most complex client group. We have a very good rapport with the local services and they often express that they feel we absolutely do thing as needed to provide best care and sometimes this is in the most extreme circumstances. We will of course continue to monitor the service quality and identify areas of improvement required and ensure that the staff are offered suitable training and ongoing supervision and support as required. Many thanks The team at Bromford lane care centre
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