Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0428, written 23 Dec 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Dec 2021 |
|---|---|
| Reference | 2021-0428 |
| Deceased | Dilys Etchells |
| Coroner | Martin Fleming |
| Coroner area | West Yorkshire Western |
| 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.
IN THE WEST YORKSHIRE WESTERN CORONER'S COURT IN THE MATTER OF: The Inquests Touching the Death of Dilys Greta Etchells A Regulation Report - Action to Prevent Future Deaths THIS REPORT IS BEING SENT TO: - Regional Care Home Manager for Aden Nursing Home 1 CORONER Martin Fleming HM Senior Coroner for West Yorkshire Western 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 16/7/21, I opened an inquest into the death of Dilys Greta Etchells who, at the date of her death was aged 90 years old. The inquest was resumed and concluded on 29/10/21 I found that the cause of death to be: - la Aspiration pneumonia lb Advanced Alzheimer' s Dementia II Traumatic fractures of left tibia and fibula I concluded with a narrative conclusion as follows: On 3/6/21 Dilys Greta Etchells, who suffered with Alzheimer' s was found on the floor of her room at Aden Court Nursing home by her nursing staff after an unwitnessed fall from her bed. After examination, she was placed back in the bed. Thereafter, on 6/6/21 nursing staff reported her left leg to be swollen and discoloured and she was taken to hospital where she was found to have suffered a fractured tibia and fibula, and her leg was placed in a cast before she was discharged back to the care home. Subsequently, she attended an outpatient's appointment at the fracture clinic on 24/6/21 in order to review the cast on her left leg, when an examination confirmed that she had developed an ulcer behind the knee to the cast. As a result, she was admitted to hospital, but despite treatment she succumbed and died on 2/7/21. It is found more likely than not that she received suboptimal care whilst she was a resident at Aden Court Nursing RT3589 1 Horne, given that at the time of her fall precautionary measures were not in place to prevent it and basic checks were not carried out to monitor her state of health thereafter. 4 CIRCUMSTANCES OF THE DEATH Upon 3/6/21 Dilys was found on the floor in her room at her nursing home at Aden Court at approximately 3am by nursing staff. At the time she was examined, no injuries were reported and she was placed back into her bed. Subsequently on 6/6/21 her GP was called out after her care staff found her left leg to be swollen and discoloured. This resulted in her admission to Huddersfield Royal Infirmary due to a suspected leg fracture. At the hospital it was confirmed she had sustained a fractured tibia and fibula and her leg was placed in a cast before she was discharged back to her care home. Thereafter on 24/6/21, Dilys attended an outpatient's appointment at the fracture clinic at HRI in order to review the cast on her leg and it was then that the tissue viability nurse found her to have developed pressure ulcers to 4 areas of her left leg and ongoing sores to her right foot, such that she was admitted to ward 19, but notwithstanding treatment she succumbed and passed away on 2/7/21. At the inquest it was accepted by the care home that Dilys had received sub optimal care given that there was no evidence to suggest that crash and sensor mats were positioned under her bed at the time of the fall and no evidence to confirm how long she had been lying on a hard floor between 2am and 3am. Thereafter, when she was discovered, it was accepted that she should have been immediately referred to a hospital doctor, and there was found to be no supportive documentation to cover her treatment and care leading up to and after admission, particularly with respect to the pressure sores and any advice given by the hospital. 5 CORONER'S CONCERNS The MATTER OF CONCERN is as follows: - • To review and reconsider the adequacy of the provision of crash and sensor mats and the means for properly documenting their use and reporting accidents when they take place. RT3589 2 • • To review existing practices with regard to the adequacy of note taking and to consider protocols to ensure compliance with care plans. To give consideration to staff training with respect to visual checks at handover to ensure resident's needs are met in accord with the care plans. • Consider the adequacy of the supporting documentation with • regard to visual checks on residents in their rooms. To consider the necessity of staff training with regard to communications at handover and dealing with correspondence received from the hospital with regard to patient care. • To review existing protocols governing wound management, completion of admission documentation, care plans, initial wound assessment, body maps, consent to medical treatment form and the return from hospital form. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that Aden Nursing Home, has the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed. 8 COPIES I have sent a copy of this report to: - Daughter • • • CQC Chief Coroner 9 DATED this 23/12/21 f¼D~ RT3589 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.
11Th February 2022
Mr Martin Fleming
HM Senior Coroner
HM Coroner’s Office
City Courts
The Tyrls
Bradford
West Yorkshire
BD1 1LA
Dear Mr Fleming
Head Office:
Hill Care Group
5 Dunston Place
Dunston Road
Chesterfield
Derbyshire
S41 8NL
E: enquiries@hillcare.net
Re: Inquest touching the death of Dilys Etchells
I write in response to the Regulation 28 report dated 23 December 2021, which was issued to Aden
Court Care Home following the above inquest. In preparing this response, I have discussed the issues
raised with colleagues and have provided information and assurance in relation to each point raised
below.
The issues raised within the report are detailed below in bold and the response is laid out underneath.
Several changes have been made at Aden Court following Mrs Etchell’s death. In addition to the
changes outlined below, there has been a change in local leadership and since August 2021,
has been the Registered Manager of Aden Court.
is a Registered General Nurse
and was in part recruited for the role because she has the necessary knowledge and skill base to
provide clinical oversight. In addition, she was previously the Deputy Manager at Aden Court before
therefore has prior knowledge of
taking up a Registered Manager role at another home.
Aden Court, as well as previous experience as a Registered Manager during which she has
demonstrated a proven track record of ensuring the provision of high quality, safe and effective care
through effective leadership. Hill Care and the staff at Aden Court are committed to providing high
quality care and continuous service development.
Please may I reiterate our sincere condolences to Mrs Etchell’s family.
1. To review and reconsider the adequacy of the provision of crash and sensor mats and the
means for properly documenting their use and reporting accidents when they take place.
All new admissions to Aden Court are pre-assessed to determine whether their needs can be
appropriately and safely met by the service. This is a detailed, holistic assessment which
includes an assessment of an individual’s level of mobility and falls risk. In undertaking the
pre-admission assessment, care home staff will obtain a full and detailed understanding of an
Registered Office: 91-97 Saltergate, Chesterfield, Derbyshire, S40 1LA. Registered in England 08902865
Hill Care Holdings Limited
individual’s needs by reviewing relevant records and speaking with the individual, their family
and social worker or hospital staff (if relevant).
If it is determined that a new service user requires any equipment (including tumble and
sensor mats) to meet their assessed needs, it will be made available and be in situ before the
new service user is admitted to the home; the service user will not be admitted until the
equipment is available. Aden Court has an agreement in relation to service users funded by
the Local Authority, whereby Kirklees Council will loan any required equipment that is needed
to meet a service user’s assessed needs. Meetings are held twice weekly between Aden Court
and colleagues within the Local Authority’s Discharge to Assess (D2A) Team, during which
forthcoming admissions are discussed including any equipment needs. The Home Manager
will attend these meetings on a weekly basis to ensure that the local management team have
oversight of new admissions. As Regional Manager, I will also attend the meetings with the
D2A team on a weekly basis to provide additional senior oversight. Privately funded service
users are also reviewed and discussed prior to their admission, however, any additional
equipment that they may need will be ordered and can be obtained within 24 hours. As
outlined above, new residents are not admitted to Aden Court unless / until any necessary
equipment is in place.
Staff at Aden Court also have access to a community nurse from the D2A team, who they can
contact for advice and guidance or if they have any concerns about a service user. In addition,
Hillcare has put in place clinical nurses at director level, for each home who provide an
additional layer of clinical oversight and guidance for staff.
In addition, all care homes owned and operated by Hill Care have their own stock of tumble
and sensor mats. This ensures that this equipment is immediately available should a resident’s
needs change at short notice. If the need for tumble and sensor mats exceeds the available
stock within a home, additional equipment can be obtained urgently and within a 24 hour
period.
In addition, equipment can also be transferred between homes in the same locality on a short
term basis, whilst longer term arrangements are made (for example if service user’s needs
change suddenly following their admission and the stock equipment is already in use). Staff
will also take steps to ensure that a service user’s needs can be safely met in the meantime
whilst any equipment is being obtained (for example, by moving rooms so that they can be
closely supervised by staff). It is the responsibility of the care home manager to keep the stock
level under regular review and ensure that it is sufficient.
Going forward, where new beds are ordered by Aden Court they will be replaced with high-
low beds which can be used a regular profiling bed or, if a service user’s needs change they
can be lowered to help manage falls risk. This approach has also been introduced as a wider
action across Hillcare.
Service users’ equipment needs are documented in their individualised care plans; both within
the main body of the document and also set out within the ‘key risk summary’ section, which
is on the front page. This information is also documented in the daily handover sheets, which
enable staff to check at each handover that each service user has the correct equipment in
situ.
Registered Office: 91-97 Saltergate, Chesterfield, Derbyshire, S40 1LA. Registered in England 08902865
Hill Care Holdings Limited
The Registered Manager undertakes regular audits. The Home Managers Weekly Audit
includes consideration of the home environment, documentation, care plans, medication and
equipment. In addition, specific equipment audits are carried out on a monthly basis to ensure
that all service users have the equipment that they have been assessed as requiring. In
preparing this response, I have reviewed the audit results and am assured that Aden Court is
100% compliant with the equipment audit. Any areas issues highlighted on audit are taken up
with the member(s) of staff involved and feedback is provided to them by the Home Manager.
Where appropriate, additional training will also be provided to members of staff (see below).
In the event that a service user has an accident, staff will complete an Accident Form. Staff
are required to document the details surrounding the incident that has taken place. The form
is then submitted to the Home Manager who will then undertake an investigation into the
circumstances of the incident to determine its root cause and whether any action is required
to prevent reoccurrence and / or improve service provision. This process is in addition to the
service user being assessed by nursing staff to determine whether they require any medical
care and treatment following the incident.
The Home Manager has daily flash meetings with care staff, in which they will ensure that
staff are aware of the requirements surrounding accident reporting and the process for
assessing new admissions and equipment needs etc. In addition, in my role as Regional
Manager, I have weekly team meetings in which information is shared with care home staff
to ensure that they are aware of the required processes and policies within the home. All
Hillcare policies are easily accessible to staff within the home.
2. To review existing practices with regard to the adequacy of note taking and to consider
protocols to ensure compliance with care plans.
There is a clear expectation that staff complete clear, accurate and up to date documentation.
This is set out within Hill Care’s policies and procedures, which staff should be familiar and
comply with as part of their day to day practice.
All new starters receive induction training and will be ‘buddied up’ with an experienced
colleague for the first few months of their new role. The induction training includes
documentation.
In addition, I provided a training session to all the Registered General Nurses and Shift Leaders
at Aden Court on 2 July 2021 (see below). Part of the session covered expectations around
documentation and specifically how staff should complete Hill Care’s standard proforma
documentation including; admission documentation, care plans, initial wound assessment,
body maps, consent to medical treatment form and return from hospital form. Following the
session, all attendees confirmed that they were aware of and understood Hill Care’s policies
and procedures in relation to documentation and that they had received training on how
documentation must be completed.
The Registered Manager of Aden Court undertakes regular care plan audits. If any non-
compliance is highlighted as part of the audit process, feedback will be provided to staff
within the flash meetings. All staff at Aden Court also have regular 1:1s with the management
Registered Office: 91-97 Saltergate, Chesterfield, Derbyshire, S40 1LA. Registered in England 08902865
Hill Care Holdings Limited
team, which provides a further opportunity for feedback to be provided and learning to be
disseminated. In addition, end of the month meetings take place which are an opportunity to
examine and consider any lessons learned and action that may be needed.
Care plan training, sourced by our training development team, was delivered 2 and 3
November 2021.
As outlined above, all prospective service users must have a completed pre-admission
assessment in place (which includes an initial care plan and risk assessments) before they can
be admitted to Aden Court. Following admission, service users’ risk assessments must be
reviewed and updated within 12 hours and then again at 24 and 72 hours following their
admission. Care plans and risk assessments are then reviewed and updated on a monthly basis
or whenever a service user’s presentation and/or needs change.
The Home Manager carries out a three weekly audit of service user’s care plans to ensure that
they are accurate, fully completed and have been reviewed and updated in line with Hill Care’s
policy. As Regional Manager, I carry out additional care plan audits on a monthly basis. Any
non-compliance is addressed directly with the member(s) of staff involved by the Home
Manager and where appropriate, additional training is arranged.
There are plans to further improve the service provision within Hill Care homes during the
course of 2022 by i) putting in place a training planner in each care home and ii) implementing
“e-care plans”.
The training planner is now in place. Home Managers can log into it and see the training diary
for the year ahead. Members of staff can log into the training planner and access e-learning
sessions. The updated training system makes it easier for training to be provided and arranged
and for training compliance to be monitored by the management team. The training planner
covers all mandatory training, including documentation and care planning as well as
addressing any additional training needs that may be identified.
The Registered Manager at Aden Court carries out regular staff observations to check the
knowledge and understanding of members of staff and provide assurance that the correct
practices are being adhered to. Again, any non-compliance or feedback is addressed within
staff 1:1s and / or the flash meetings.
Hill Care will be implementing e-care plans by Summer 2022. It had been planned that the
move to electronic care plans would be sooner, but unfortunately this development was
delayed because it was necessary to focus on the management of our response to the Covid-
19 pandemic. The move towards electronic care plans will mean that there will no longer be
any issues with regards to the legibility of entries. The new electronic system will also make
it quicker to audit documentation, enabling any necessary action to be taken swiftly to
rectify any identified non-compliance. The system will also provide staff with prompts to
complete relevant care plans and in circumstances where a care plan requires review, it will
not allow the user to move onto the next page unless and until that care plan has been
reviewed and updated.
Registered Office: 91-97 Saltergate, Chesterfield, Derbyshire, S40 1LA. Registered in England 08902865
Hill Care Holdings Limited
I delivered a training session on 2 July 2021, which was attended by all the Registered
General Nurses and Shift Leaders at Aden Court. The session covered the use of Hill Care’s
standard proforma documentation including; the correct completion of admission
documentation, care plans, initial wound assessment, body maps, consent to medical
treatment form and return from hospital form.
In addition, external training on care plans was sourced by Hall Care’s training development
team and provided to staff on 2 and 3 November 2022. The training session focused on
person centred care plans and how they should not be seen as static documents but rather
continually kept under review, updated and developed during a service user’s admission.
There are plans to put in place a training planner at each home, including Aden Court. This
will be kept under review by the home managers, to ensure that staff are up to date with
their training requirements.
Compliance with documentation, including care plans is monitored by the care home
managers who carry out a three-weekly audit. In addition, in my role as Regional Manager, I
undertake a care plan audit on a monthly basis. If any non-compliance is identified by the
audit, the home manager will take this up with the individual member of staff involved. This
will include a 1:1 session with the home manager to provide feedback and reiterate the
importance of good documentation and may also include additional training if considered
necessary.
Hill Care will be implementing e-care plans by Summer 2022. It had been planned that the
move to electronic care plans would be sooner, but unfortunately this development was
delayed because it was necessary to focus on the management of our response to the Covid-
19 pandemic. The move towards electronic care plans will mean that there will no longer be
any issues with regards to the legibility of entries. The new electronic system will also make it
quicker to audit documentation, enabling any necessary action to be taken swiftly to rectify
any identified non-compliance. The system will also provide staff with prompts to complete
relevant care plans and in circumstances where a care plan requires review, it will not allow
the user to move onto the next page unless and until that care plan has been reviewed and
updated.
3. To give consideration to staff training with respect to visual checks at handover to ensure
residents’ needs are met in accordance with the care plans.
As outlined in my witness statement dated 11 November 2021, handovers are now carried
out as ‘walk around; handovers rather than taking place in an office. The walk around
handovers take place twice a day and are attended by the Home Manager, Registered General
Nurses and Shift Leaders, ensuring that senior staff see all the service users face to face.
Handover sheets have been developed to ensure that all relevant information is passed on
and checks completed as part of the handover process, including: name of the resident, date
of the handover, outgoing / incoming member of staff with responsibility for the resident, the
residents assessed needs and any equipment that they require to meet their assessed needs.
There are two tailored handover sheets; one for residential service users and another for
nursing service users.
Registered Office: 91-97 Saltergate, Chesterfield, Derbyshire, S40 1LA. Registered in England 08902865
Hill Care Holdings Limited
The change in the way that handovers are carried out has been reflected in Hill Care’s
Quality and Governance Programme and it is the responsibility of the home manager to
ensure that handovers take place in this way.
The Registered General Nurses and Shift Leaders have been informed of the new handover
process by the Home Manager during weekly team meetings. To ensure that this change
becomes embedded in day to day practice, the Home Manager carries out audits of the
handover sheets as part of the weekly quality programme to ensure that the documented
information accords with the detailed care plan and that the handover sheet has been fully
completed. In my role as Regional Manager, I also undertake monthly audits of the handover
sheet and process for further organisational assurance that the correct process is being
following by members of staff.
In addition, as outlined in my witness statement a full audit of all equipment was carried out
on 7 July 2021 to ensure that all items of equipment stipulated as being required by service
users’ care plans were in fact in place. The outcome of this audit was reassuring, with 100%
of the audited service users having the necessary equipment in place to meet their assessed
needs. Since September 2021, the equipment audit has been undertaken on a monthly basis
to provide ongoing organisational assurance that the provision on equipment matches
assessed needs documented on care plans. As outlined above, Aden Court has obtained 100%
compliance in meeting service user’s equipment needs.
Where any non-compliance or deviation from policy requirements is highlighted by an audit,
this is taken up directly by the Home Manager with the member(s) of staff concerned and
actioned immediately. If necessary, additional training will be provided.
4. Consider the adequacy of the supporting documentation with regard to visual checks on
residents in their rooms.
As outlined above, handover sheets have been developed to ensure thorough handover of
information (including the outcome of visual checks) as part of the twice daily handover
process.
In addition to the visual checks that now form part of the handover process, service users are
checked on an hourly basis throughout the day if they are in their rooms. If service users
decide to spend time in one of the communal areas, specific hourly checks are not undertaken
as they are ‘cohorted’ with other service users. The hourly checks and cohorted supervision
are in addition to any observations or interventions that may be required from a nursing
perspective (for example in relation to an incontinent individual).
Staff are required to document the outcome of the hourly checks in the notes. All staff have
been reminded of the need to ensure that hourly visual checks are carried out in relation to
service users in their rooms and that a contemporaneous note is made. Compliance with this
requirement will be audited by the Home Manager as part of their regular care plan audits
outlined above and any non-adherence will be addressed directly with the member(s) of staff
involved.
Registered Office: 91-97 Saltergate, Chesterfield, Derbyshire, S40 1LA. Registered in England 08902865
Hill Care Holdings Limited
5. To consider the necessity of staff training with regard to communications at handover and
dealing with correspondence received from the hospital with regard to patient care.
Following Mrs Etchell’s death, the handover process was reviewed and updated to ensure that
information is effectively communicated as part of that process. As outlined above, handover
sheets have been developed which set out what information must be handed over and what
checks must be undertaken at handover either by the Registered Nurses or Shift Leaders.
Following the walk around handover, senior staff members will then provide an update to
their junior team members so that they are aware of the information discussed at handover.
During regular team meetings, the Home Manager has informed all members of staff in
relation to the new two-stage handover process and what is expected from them as part of
that process. Compliance with the new process will be monitored by way of ongoing regular
audits, as outlined above.
Since October 2021, where consent is provided service users’ post is opened by the Home
Manager and admin staff. If correspondence relates to hospital outpatients’ appointments,
the appointments are noted in the diary and in the service user’s individual care plan. If any
information is provided relating to patient care, this is also documented in the care plan. The
Registered General Nurses and Shift Leaders review the diary as part of the daily handover
process to ensure that no appointments are missed. Any patient care advice will inform the
care plan, which as outlined above are regularly reviewed and audited.
In addition, we are currently liaising with the hospital’s Tissue Viability Team to develop a care
plan for patients who are discharged to our care. This will be in addition to the wider
individualised care plans that will be put in place for all new admissions (or re-admissions
following a hospital admission). Staff are also encouraged to contact ward staff if they have
any questions or concerns regarding the management of service users who have recently been
in hospital or have been seen in outpatients’ clinic.
6. To review existing protocols governing wound management, completion of admission
documentation, care plans, initial wound assessment, body maps, consent to medical
treatment form and the return from hospital form.
There are clear protocols in place within Aden Court in relation to wound management,
admission documentation, care plans, initial wound assessment, body maps, consent to
medical treatment form and the return from hospital form. As outlined above, I provided a
training session for all the Registered General Nurses and Shift Leaders on 2 July 2021. The
session covered wound management, completion of admission documentation, care plans,
initial wound assessment, body maps, consent to medical treatment form and the return from
hospital form to ensure that they were aware of the protocols in place within Aden Court.
Compliance is monitored through an ongoing, regular and thorough audit process. I have
provided more detail below.
The Registered Manager carries out weekly wound audits, which look at wound management
and assessment. The use of body maps is reviewed as part of the weekly care management
review that is also undertaken by the Registered Manager.
Registered Office: 91-97 Saltergate, Chesterfield, Derbyshire, S40 1LA. Registered in England 08902865
Hill Care Holdings Limited
Hill Care’s protocol in relation to the completion and review of admission documentation and
care plans is outlined above. The Registered Manager will carry out a full review of the
admission documentation and initial care plans to ensure that they are full and thorough and
accurately document the service user’s needs. Care plans are then kept under review and
monitored through the regular and ongoing care management review process, during the
course of a service user’s admission.
On admission, service users with capacity will sign the consent to medical treatment form.
Otherwise a Power of Attorney will be appointed or treatment provided in their best interests,
having undertaken the best interests decision making process under the Mental Capacity Act.
Service users returning from hospital will be discussed in the flash meetings to ensure that the
discharge summary has been provided by the hospital, as well as any medication and / or
follow up advice and guidance. Aden Court has been liaising with hospital staff in relation to
service users returning or being admitted to home with a cast in situ and it has been agreed
that hospital staff will produce initial care plans, setting out advice and guidance for care home
staff in relation to how to manage the cast and the service user following their discharge from
hospital.
I trust this letter has addressed the concerns raised. However, please do not hesitate to contact
me should there be any outstanding issues.
Yours sincerely,
Regional Manager
Registered Office: 91-97 Saltergate, Chesterfield, Derbyshire, S40 1LA. Registered in England 08902865
Hill Care Holdings Limited
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