Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0008, written 11 Jan 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Jan 2022 |
|---|---|
| Reference | 2022-0008 |
| Deceased | Reginald Weston |
| Coroner | Myfanwy Buckeridge |
| Coroner area | Avon |
| 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.
M. E. Voisin
Her Majesty’s Senior Coroner
Area of Avon
11th January 2022
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: Management, Blenheim House Care Home
1
CORONER
I am Myfanwy Buckeridge Assistant Coroner for Area of Avon
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On 04/08/2021 I commenced an investigation into the death of Reginald Howard Weston. The
investigation concluded at the end of the inquest. The conclusion of the inquest was Accident
4
CIRCUMSTANCES OF THE DEATH
Mr Weston died due to injuries sustained in a fall on 7 July 2021. It was identified in evidence that he
had moved and bypassed the sensor mat that had been placed at his feet and that care staff were aware
he had done so on previous occasions. Although the presence of an in-place sensor mat unlikely made a
difference in Mr Weston’s fall, it may do so in different circumstances where a resident is known to
bypass the sensor mat. He had fallen twice on 4 July 2021 but there was no evidence to indicate his falls
risk assessment was reviewed following those falls and recorded as required by the Majisticare Falls
Management Policy and Procedure.
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 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. –
Evidence was given in relation to the Majesticare Falls Management Policy and Procedure requirement to
record a review of the resident’s risk assessment in the context of 2 recorded falls on 4 July 2021.
Blenheim House management need to consider:
a) Documentation demonstrating a review of the resident’s risk assessment has taken place
following a fall
b) Timely process for completing it
The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL
Website www.avon-coroner.com
6
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.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by 8th
March 2022. 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 – the family
of the deceased.
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.
9
11/01/2022
Signature
Myfanwy Buckeridge Assistant Coroner Area of Avon
The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL
Website www.avon-coroner.com
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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS FROM: Management Team, Blenheim House Care Home The MATTERS OF CONCERN expressed by the Coroner were as follows. – Evidence was given in relation to the Majesticare Falls Management Policy requirement to record a review of the resident’s risk assessment in the context of 2 recorded falls on 4 July 2021. Blenheim House management need to consider: Documentation demonstrating a review of the resident’s risk assessment has taken place following a fall Timely process for completing it Response 1. Further to the inquest onto the death of Mr Weston and the Report issued by the Coroner, the management team at Blenheim House have carefully considered the concerns expressed in relation to Mr Weston and have reviewed the Majesticare Falls Management Policy and Procedure. 2. All falls, care plans and risk assessments continue to be reviewed post fall as the position was previously; however a new timescale has been added that the fall needs to be recorded and the risk assessment needs to be completed within 24 hours of any fall. This has been communicated to staff together with an explanation as to why this data is critical in assessing a service users fall risk. A copy of the risk assessment is provided in Appendix 1 to this response. 3. Monthly clinical and governance meetings continue to be held with the senior team, trends and patterns are identified in accidents and incidents audit from each month with monthly action plans in place. A weekly care review meeting is now also being explored to support this governance process. 4. Alongside care plans and risk assessments reviews during resident of the day, falls equipment audits have taken place in July, October and January by the Deputy Manager and the Home Manager. Daily walk round checks of equipment continue to take place. 5. In addition, more detailed accident and incident analysis has been included into the monthly accident audit. 6. Pre-admission assessments are now taking place in person when possible so that a proper assessment from a residential or nursing care perspective can be carried out. All residents at high risk of falls are identified at ‘high risk’ of falls prior to admission and the General Manager will seek the additional support of 1:1 care during required isolation period. 7. The Berkley Care Group Training Manager is also supporting Blenheim House with additional Falls Prevention Champion Training in Q2.
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