Prevention of Future Deaths reports
Regulation 28 report to prevent future deaths, reference 2021-0307. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Reference | 2021-0307 |
|---|---|
| Deceased | Irene Esaw |
| Coroner | Anna Morris |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Community health care · Other related deaths |
| Organisation named | Tameside and Glossop Integrated Care NHS Foundation Trust |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive Tameside and Glossop Integrated Care NHS Foundation Trust 1 CORONER I am Anna Morris, assistant coroner, for the coronial area of Manchester South 2 CORONER’S LEGAL POWERS 3 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 11th September 2019 an investigation into the death of Irene Ann Esaw, aged 73 years. The investigation concluded at the end of the inquest on 6th September 2021. The conclusion of the inquest was a narrative conclusion. 4 CIRCUMSTANCES OF THE DEATH The deceased lived at home with her 24-year-old grandson, who was her sole carer. The deceased suffered from dementia which was diagnosed in 2015. From October 2017, there was no formal support in place from external agencies. From that point, the deceased’s grandson was responsible for attending to all the deceased’s nutritional, mobility, hygiene and personal care needs. This was an unmanageable care burden for her grandson. On the 12th September 2018, the deceased was admitted to hospital in extremis. She was malnourished, dehydrated, and confused. A safeguarding concern was raised by Northwest Ambulance Service (NWAS) who were concerned about her physical presentation, her social circumstances and the care being provided to her by her grandson. Her presentation was such that it was known or ought to have been known to those treating her that she was a vulnerable adult. The deceased was admitted to Tameside General Hospital and treated for sepsis and her other acute medical conditions. The NWAS safeguarding concern was referred to the IUCT Social Workers at the hospital provided by the Tameside Metropolitan Borough Council based at the hospital. There was an assessment on the 26th September by a social worker of the deceased’s care needs. This assessment failed to properly assess the deceased’s capacity to make decisions about her own care needs or where and by whom they should be met. It was assessed that there were no needs identified and no support was put in place for either the deceased or her grandson. The deceased was discharged from hospital on the 28th September 2018 without any package of care in place from the Local Authority or any referrals in place from the Hospital to community-based services. At the time the deceased was discharged, a Grade 1 pressure sore to her sacrum had been identified, as well as other areas of reddening of the skin on her lower limbs. The identification of a Grade 1 pressure sore by the hospital, considering her nutritional needs and her difficulties with maintaining her own nutrition, hydration and mobility made her extremely high risk of not being able to maintain her own tissue viability. Without appropriate support I find that it was 1 inevitable that the deceased would develop sores not just on her sacrum but in other areas and that she would have been too weak to mobilise herself and with her level of cognition she would not have been able to recognise her need to move herself. This should have been identified by the hospital and the deceased should have been provided with adequate support post discharge. In hospital, the deceased had benefitted from high grade medical care with nursing support and that this level of care would have been appropriate to deal with her ongoing pressure, nutritional and cognitive needs. As a consequence, I find that the Trust failed to meet the deceased’s basic medical needs following discharge from hospital. As that support was not put in place, the deceased’s grandson was not able to meet her complex care needs in the community. Her grandson also likely suffered from poor mental health because of his care burden. His needs as a carer were not adequately assessed or addressed at any stage during 2017- 2018. As a consequence, I find on the balance of probabilities that her grandson did not meet the deceased’s basic nutritional and personal care needs from the point of her discharge from hospital on the 28th September 2018 to the time of her death. As a direct result of the failure of the deceased’s basic needs being met, her Grade 1 sacral pressure sore developed to a deep and infected ulceration that subsequently caused the bone to be exposed and infected. She also developed another significant ulcer that connected to her sacral ulcer and other areas of tissue damage. As a result of those untreated pressure sores, the deceased developed widespread sepsis. On the 11th November 2018, her grandson called for an ambulance. When paramedics attended at her home address, they found Mrs. Esaw in bed, propped upright and clearly deceased. The state of her clothing and the bedding was soiled with both faeces and urine and the deceased was found in an emaciated state due to malnutrition. 2 5 CORONER’S CONCERNS The MATTERS OF CONCERN are as follows. – 1. Identifying and Assessing Mental Capacity – My findings in relation to Mrs. Esaw’s death were that there was a fundamental failure by the clinical and nursing staff to adequately consider and assess Mrs. Esaw’s capacity to make decisions about her own care needs whilst she was a patient at Tameside General Hospital between 12th and 28th September 2018. This failure in my view, undermined her discharge planning and was one of the key reasons why the discharge was unsafe. I understand that work is ongoing in this area, but I am concerned having heard the evidence of Deputy Director of Nursing and Professional Standards that it is still a “work in progress” identified by this and other incidents reported to the Trust. I am concerned that there are still issues that the Trust still aren’t completely compliant with and that this needs to be addressed. , the 2. Recognising the Clinical Signs of Neglect – My findings indicate that in 2018 there was no adequate consideration by the clinical or nursing staff that Mrs. Esaw’s clinical presentation in of itself indicated neglect and therefore a safeguarding concern. The Trust’s Safeguarding Lead Domestic Homicide Review, the Trust recognises that more work needs to be done around the recognition of what is neglect and those medical indicators of neglect. She recognised that there needs to be a strengthening of recognition in staff of safety concerns. I understand that this is part of the Safeguarding Lead’s portfolio, but I am concerned that this still needs to be addressed. told me that following on from the 3. Multi-agency Working – My findings reveal that in the treatment of Mrs. Esaw, there were assumptions made by the clinical team and the IUCT that the other agency was responsible for capacity and needs assessments. The effect of this was that there was never an adequate assessment of her needs completed. Care told me in her evidence that even though IUCT are on the wards at Tameside, there is still further work to be done to understand the roles that the IUCT and the clinical team are undertaking. I am concerned that this continues to need to be addressed. , the Principal Social Worker for Adult Social 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of this report, namely by 11th November 2021. I, the coroner, may extend this 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: Chief Executive Tameside Metropolitan Borough Council. NHS England I am also under a duty to send a copy of your response to the Chief Coroner 3 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 16th September 2021 Anna Morris – Assistant Coroner Signed: 4 REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive Tameside Metropolitan Borough Council. 1 CORONER I am Anna Morris, assistant coroner, for the coronial area of Manchester South 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 11th September 2019 an investigation into the death of Irene Ann Esaw, aged 73 years. The investigation concluded at the end of the inquest on 6th September 2021. The conclusion of the inquest was a narrative conclusion. 4 CIRCUMSTANCES OF THE DEATH The deceased lived at home with her 24-year-old grandson, who was her sole carer. The deceased suffered from dementia which was diagnosed in 2015. From October 2017, there was no formal support in place from external agencies. From that point, the deceased’s grandson was responsible for attending to all the deceased’s nutritional, mobility, hygiene and personal care needs. This was an unmanageable care burden for her grandson. On the 12th September 2018, the deceased was admitted to hospital in extremis. She was malnourished, dehydrated, and confused. A safeguarding concern was raised by Northwest Ambulance Service (NWAS) who were concerned about her physical presentation, her social circumstances and the care being provided to her by her grandson. Her presentation was such that it was known or ought to have been known to those treating her that she was a vulnerable adult. The deceased was admitted to Tameside General Hospital and treated for sepsis and her other acute medical conditions. The NWAS safeguarding concern was referred to the IUCT Social Workers at the hospital provided by the Tameside Metropolitan Borough Council based at the hospital. There was an assessment on the 26th September by a social worker of the deceased’s care needs. This assessment failed to properly assess the deceased’s capacity to make decisions about her own care needs or where and by whom they should be met. It was assessed that there were no needs identified and no support was put in place for either the deceased or her grandson. The deceased was discharged from hospital on the 28th September 2018 without any package of care in place from the Local Authority or any referrals in place from the Hospital to community-based services. At the time the deceased was discharged, a Grade 1 pressure sore to her sacrum had been identified, as well as other areas of reddening of the skin on her lower limbs. The identification of a Grade 1 pressure sore by the hospital, considering her nutritional needs and her difficulties with maintaining her own 1 nutrition, hydration and mobility made her extremely high risk of not being able to maintain her own tissue viability. Without appropriate support I find that it was inevitable that the deceased would develop sores not just on her sacrum but in other areas and that she would have been too weak to mobilise herself and with her level of cognition she would not have been able to recognise her need to move herself. This should have been identified by the hospital and the deceased should have been provided with adequate support post discharge. In hospital, the deceased had benefitted from high grade medical care with nursing support and that this level of care would have been appropriate to deal with her ongoing pressure, nutritional and cognitive needs. As a consequence, I find that the Trust failed to meet the deceased’s basic medical needs following discharge from hospital. As that support was not put in place, the deceased’s grandson was not able to meet her complex care needs in the community. Her grandson also likely suffered from poor mental health because of his care burden. His needs as a carer were not adequately assessed or addressed at any stage during 2017- 2018. As a consequence, I find on the balance of probabilities that her grandson did not meet the deceased’s basic nutritional and personal care needs from the point of her discharge from hospital on the 28th September 2018 to the time of her death. As a direct result of the failure of the deceased’s basic needs being met, her Grade 1 sacral pressure sore developed to a deep and infected ulceration that subsequently caused the bone to be exposed and infected. She also developed another significant ulcer that connected to her sacral ulcer and other areas of tissue damage. As a result of those untreated pressure sores, the deceased developed widespread sepsis. On the 11th November 2018, her grandson called for an ambulance. When paramedics attended at her home address, they found Mrs. Esaw in bed, propped upright and clearly deceased. The state of her clothing and the bedding was soiled with both faeces and urine and the deceased was found in an emaciated state due to malnutrition. 2 5 CORONER’S CONCERNS The MATTERS OF CONCERN are as follows. – Identifying and Assessing Mental Capacity – My findings in relation to Mrs. Esaw’s death were that there was a fundamental failure by the local authority staff to adequately consider and assess Mrs. Esaw’s capacity to make decisions about her own care needs whilst she was a patient at Tameside General Hospital between 12th September 2018 and the time of her death. This failure in my view, undermined her discharge planning and was one of the key reasons why the discharge was unsafe. I understand that work is ongoing in this area by in relation to prompting and recording of consideration of capacity concerns but, I also have concerns about a lack of professional curiosity by social workers, which I understand is still to be addressed in an ongoing piece of work for the new Safeguarding Lead who has yet to start in post. Therefore, I am concerned that the area of inquiring about and assessing capacity continues to need to be addressed. Multi-agency Working – My findings reveal that in the Care assessments of Mrs. Esaw, there were assumptions made by the clinical team and the IUCT that the other agency was responsible for capacity and needs assessments. The effect of this was that there was never an adequate assessment of her needs completed. , the Principal Social Worker for Adult Social Care told me in her evidence that even though IUCT are on the wards at Tameside, there is still further work to be done to understand the roles that the IUCT and the clinical team are undertaking. I am concerned that this continues to need to be addressed. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of this report, namely by 11th November 2021. I, the coroner, may extend this 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: Chief Executive Tameside and Glossop Integrated Care NHS Foundation Trust 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 3 9 16th September 2021 Anna Morris – Assistant Coroner Signed: 4
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.
A1 A2 A3 A4 A5 A6 A7 CHIEF EXECUTIVE
Chief Executive, Tameside MBC
and Accountable Officer, Tameside & Glossop CCG
Tameside One, Market Place, Ashton under Lyne, OL6
6BH
Doc Ref
let/sp1211
Date
10 November 2021
Ms Anna Morris
Assistant Coroner
Coroner's Court
1 Mount Tabor Street
STOCKPORT
SK1 3AG
Dear Ms Morris
Re: Regulation 28 Report into the death of Irene Ann Esaw (dob 13/11/1934, dod 11/11/2018)
Further to your letter and Regulation 28 Report to Prevent Future Deaths dated 16 September
2021, regarding the tragic case of Irene Ann Esaw please find my response outlined below.
The untimely death of a person is distressing for their family and any others affected by their death
and loss, and all the more so if there is any belief that but for the actions of any public sector
organisation it could have been avoided.
I would like to record my sincere condolences to the family of Irene Ann Esaw for their loss and I
hope through this process they can obtain some closure.
The matters of concern identified by the Coroner and directed to the Chief Executive of Tameside
Metropolitan Borough Council were as follows:
1. Identifying and Assessing Mental Capacity
My findings in relation to Mrs. Esaw’s death were that there was a fundamental failure by
the local authority staff to adequately consider and assess Mrs. Esaw’s capacity to make
decisions about her own care needs whilst she was a patient at Tameside General Hospital
between 12th September 2018 and the time of her death. This failure in my view,
undermined her discharge planning and was one of the key reasons why the discharge was
unsafe. I understand that work is ongoing in this area by
in relation to
prompting and recording of consideration of capacity concerns but, I also have concerns
about a lack of professional curiosity by social workers, which I understand is still to be
addressed in an ongoing piece of work for the new Safeguarding Lead who has yet to start
in post. Therefore, I am concerned that the area of inquiring about and assessing capacity
continues to need to be addressed.
2. Multi-agency Working
My findings reveal that in the Care assessments of Mrs. Esaw, there were assumptions
made by the clinical team and the IUCT that the other agency was responsible for capacity
and needs assessments. The effect of this was that there was never an adequate
, the Principal Social Worker for Adult
assessment of her needs completed.
Social Care told me in her evidence that even though IUCT are on the wards at Tameside,
there is still further work to be done to understand the roles that the IUCT and the clinical
team are undertaking. I am concerned that this continues to need to be addressed.
1 | P a g e
B1
Identifying and Assessing Mental Capacity
Since 2019, one of Adult Social Care work force development priorities has been to improve our
staff knowledge and application of the Mental Capacity Act.
Tameside MBC has recognised that there is a need to invest in their workforce to ensure that they
are appropriately trained and that skills are updated and developed through a number of means.
In order to do this a number of priorities were agreed:
To improve social work standards and the quality of social work practice, assessment and
care planning.
To ensure the provision of effective support and development to managers and practitioners
to develop a skilled and confident workforce which meets the needs of the service and the
people it supports.
To offer high-quality advice, support and consultancy to social work managers to develop
social work services locally and with our partners.
A programme to embed the Mental Capacity Act in practice is underway including Mental
Capacity Assessment Forums and Social Work Forums
A Quality Assurance Framework and a Workforce Development Framework are being
developed with the aim to embed professional confidence, curiosity and development in
practice.
Adult Services has registered with Research in Practice for Adults (RiPfA) to support
managers and staff
A Social Work Consultant post has been recruited to. This post does not carry a caseload
and does not directly line manage any staff. The purpose of this management level post is to
support our professional teams, managers and staff to improve outcomes for individuals
through their improved practice.
On the 22 July 2020, a 12 month improvement plan was launched, which incorporates standards of
practice, themed audits and themed Continuing Professional Development. The Individual
Management Report (IMR) recommendations and action plan are annexed to this report as
Appendix A.
Some of the work completed has included reviewing the documentation for recording Mental
Capacity Assessments and Best Interest decisions. These have been linked to other assessments
such as the Needs assessment and Risk assessment to ensure the Mental Capacity Act is at the
heart of social work practice with adults. The revised and updated assessments (Appendix B &C
refers) and Care Act guidance for staff (Appendix D refers) are annexed to this response.
A programme of regular training has taken place and will continue as this is an area of law and
practice which changes and evolves with the changing nature of practice and case law.
The Safeguarding Lead started in their role on the 13 September 2021, they are responsible for the
implementation of the new Safeguarding Policy and Procedure within Tameside Adult Services.
One of the priorities that will run throughout all of their work will be to ensure staff feel confident
and equipped to be more ‘professionally curious’. This is recognised safeguarding training and
the toolkit, advises that social workers can become more professionally curious and respectfully
uncertain by following the points below:
1) “Question why someone is behaving in a certain way. Consider what these behaviours
could indicate.
2) Find out more about someone’s personal circumstances. Assess their behaviour in light of
what you know about them and their situation.
3) Question the motives of anyone who is with the person. Why are they there? What is
their relationship to the person? Do they appear controlling? Do they dislike leaving the
person alone? Even if they appear kind and supportive, could this be a way of hiding their
role in harming the person?
B2
4) Recognise when someone is reluctant to provide a full or accurate account of events or
is pretending to cooperate to avoid raising suspicions.
5) Think outside the box. Consider the person or situation from the viewpoint of other workers.
What might they look out for and notice? What would they think about the situation?
6) Maintain an open mind. Avoid making assumptions, taking information at face value and
jumping to conclusions. Take account of changing information and different perspectives.
Consider if you need to adapt your views.
7) Ask questions and challenge what you believe to be untrue.
8) Notice if you or someone else starts to doubt that someone is a victim – consider the
reasons for these doubts. Are they fair? It might be helpful to read more about how victims
of exploitation are perceived.
9) Trust your instinct and raise concerns if something about someone’s behaviour or situation
does not feel right.
10) Think vulnerability and exploitation – be actively aware of how anyone you come across
may be vulnerable and could be experiencing exploitation.
11) Think and act outside of your immediate job role – take action to investigate and act on
your concerns, even if this goes beyond the immediate remit of your role and
responsibilities.
12) For example, a professionally curious health professional who is treating someone for
physical injuries would also question why these injuries have been sustained and assess
the person’s wider appearance and behaviour – do they seem distressed? Are they
reluctant to say how they received their injuries? Do they seem to be hiding something? Is
there anything about them that raises concerns or suspicions?
13)If you are concerned about someone, take action to find out more about their situation and
protect their safety and wellbeing.”
Within the first month of being in the role, the Safeguarding Lead delivered a session for all social
workers and managers on the learning from this case. The session was very well attended with
over 100 attendees. Following the event, staff have been asked to discuss the learning in their
teams and then share feedback with the Safeguarding Lead on how the learning will be applied in
practice and what further support they may need. This feedback will inform their work plan.
The Safeguarding Lead’s work plan includes gaining feedback on practice in a number of ways
including conducting regular case file audits, learning reviews and consulting with all staff on a
regular basis through surveys and forums to ensure that the support provided meets the needs of
the organisation and social work standards. This approach aims to improve social worker’s
confidence, knowledge and skills in safeguarding practice and ensure staff demonstrate
professional curiosity in practice.
The Safeguarding Lead has arranged quarterly Safeguarding Practice Forums. The first of these
is planned in December 2021 and the theme will be Domestic Abuse. The ongoing training
programme for social workers and managers will be reviewed and developed by the Safeguarding
lead ensuring that staff have up to date knowledge and skills in this area of practice. There will be
a rolling programme of essential training for all practitioners to complete every 2 years, this
includes new and existing staff.
The Principal Social Worker is currently reviewing the implementation of the quality assurance
framework for social work practice, the application of the Mental Capacity Act will feature in this
work. The aim is that a new framework will be in place from January 2022. Part of this work will
include implementing the National Mental Capacity Act Competency Framework, developed by
Bournemouth University. A skills and knowledge audit will take place of social workers and
managers and the outcome will inform the ongoing training programme.
Multi-agency Working
Tameside MBC and Tameside and Glossop Integrated Care NHS Foundation Trust both received
similar Prevention of Future Death reports. In response to this and in line with Tameside MBC’s
Domestic Homicide Action Plan, a learning meeting took place on the 12 October 2021.
B3
Senior staff from both the Tameside and Glossop Integrated Care NHS Foundation Trust and
Tameside MBC met to reflect on the mechanisms in place for multiagency working at discharge
between the Integrated Urgent Care Team, the Wards, the Medics and the community
Neighbourhood Teams. The meeting was chaired by the Principal Social Worker, TMBC and the
Head of Nursing for Integrated Safeguarding, Tameside and Glossop Integrated Care NHS
Foundation Trust. The following themes were identified as areas for development in terms of
multiagency working:
• Safe Discharge
• Recognising Adults at Risk
• Roles and Responsibilities
• The Application of the Mental Capacity Act
A joint action plan for the Tameside and Glossop Integrated Care NHS Foundation Trust and
Tameside MBC has been developed, which includes developing the knowledge and skills of all the
staff involved in hospital discharge on the ward and in the community on ‘What is a Safe
Discharge?’ and ‘Who are the adults at risk? ’ through a number of ways such as training, forums,
audits and revised procedures. The joint action plan is also annexed to this response – Appendix
E refers.
Integral to this, is ensuring that the multidisciplinary team have a good understanding of one
another’s roles and responsibilities. Work will take place to ensure that this is embedded in
practice. This will include ensuring that roles and responsibilities feature in the induction of all
staff, in ongoing clinical supervision and in multiagency procedures and standards. A multiagency
review and refresh of the Mental Capacity Act procedures and training regarding adults with care
needs on discharge, will take place.
The finalised joint action plan will be shared with Tameside Adult Safeguarding Board at the next
Board meeting in December 2021. A Multiagency Action Plan Group will be established to monitor
the action plan, this will in place by December 2021. Alongside this a Quarterly Multiagency
Learning Forum will be established as a mechanism to monitor the implementation of the action
plan and to support a culture of reflection and learning across the multiagency partnership
associated with hospital discharge.
Conclusion
Tameside MBC trusts that these actions and proposals are sufficient to satisfy that Coroner that
the Council does take these concerns seriously, and that there is a continuous programme in place
to support staff knowledge in identifying and their application of the Mental Capacity Act.
Furthermore that the implementation of the joint action plan between the Council and Tameside
and Glossop Integrated Care NHS Foundation Trust will minimise the risk of inadequate multi
agency working.
I hope that we have provided you with the necessary assurances in relation to your concerns.
Please contact me if you require any further information or if I can assist further in any way.
Yours sincerely,
Chief Executive, Tameside MBC/Accountable Officer, Tameside & Glossop CCG
Attachments:
Appendix A
Appendix B
IMR Recommendations with Action Plan
Mental Capacity Assessment
B4
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