Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0210, written 12 Jul 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Jul 2022 |
|---|---|
| Reference | 2022-0210 |
| Deceased | Barbara Proudlove |
| Coroner | Jason Pegg |
| Coroner area | Hampshire, Portsmouth and Southampton |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Berkeley Home Health 1 CORONER I am Jason PEGG, Area Coroner for the coroner area of Hampshire, Portsmouth and Southampton 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 08 July 2020 I commenced an investigation into the death of Barbara PROUDLOVE aged 92. The investigation concluded at the end of the inquest on 12 July 2022. The conclusion of the inquest was that: See box 4 4 CIRCUMSTANCES OF THE DEATH The deceased died on 4th July 2020 at Southampton General Hospital, Tremona Road, Southampton, Hampshire having developed pneumonia in consequence of cardiac failure and dementia. The deceased had elevated levels of morphine and lorazepam within her body, how that came to be cannot be ascertained, which caused the deceased to be unconscious and contributed to the death. There was a delay in summoning medical assistance for the deceased which together with the deceased's frailty contributed to the death. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving 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 are as follows: (brief summary of matters of concern) The Berkeley Home Health carer did not identify that the deceased was unconscious in good time; there was delay by the carer in summoning medical assistance. The evidence of the carer demonstrated a lack of training, skills and understanding in being able to reasonably identify a medical emergency and how to respond to a medical emergency. My concern is that such carers lack the necessary training and skills when tasked with caring for others in the same position as the deceased. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or Regulation 28 – After Inquest Document Template Updated 30/07/2021 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 the date of this report, namely by September 06, 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 I have also sent it to who may find it useful or of interest. 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 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 by the Chief Coroner. 9 Dated: 12/07/2022 Jason PEGG Area Coroner for Hampshire, Portsmouth and Southampton Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
29th July 2022
Dear Jason Pegg (Area Coroner)
Regulation 28 After inquest PROUDLOVE
Group which includes Berkeley Home Health.
I am the Chief Executive Officer and Nominated Individual for Trinity
I am writing, as requested to advise of the actions taken upon receiving regulation 28 report
to prevent the risk of further deaths as identified in the report.
By way of relevant update, Berkeley Home Health is under new ownership and became part
of the Trinity Group in October 2021 and we are aware of the historic incident under the
stewardship of the previous owners when we purchased Berkeley Home Health.
The care services across the group pride themselves on Good and Outstanding ratings by
the Care Quality Commission. Berkeley Southeast since the acquisition now has a new
Registered Manager in place working alongside our Group Director of Care Services and
Regional Care Director to support the delivery of care.
Group Services
Berkeley Southeast is now fully supported by our experienced group shared services which
includes, Recruitment to recruit carers will the right skills with the ability to provide safe care.
Our Compliance department supports with regular quality assurance checks and auditing to
ensure we meet regulatory requirements and deliver high quality of care. We have an in-
house training team that delivers our carer induction and care certificate training as our
minimum standard. Each carer is assessed and signed off as competent and supported in
the field before they can lone work. Refresher training takes place annually or sooner if the
need arises to support our carers and ensure high level of quality care is provided to all our
clients.
New System
To improve visibility of the activity taking place in the service, we have introduced a new
digital care system (Access Care Planning) into Berkeley Southeast. The system allows
carers to report information or concerns via an Alert in real time, this is monitored by our
Care Managers and actioned upon receipt. Access Care Compliance allows any incidents
and accidents to be logged and investigated, any high level concerns the system will
automatically sends an alert to our Group Director of Care Services and our Group
Compliance Officer. Monthly Risk Committee meetings take place to discuss areas of
improvement, lessons learnt, process, and policy changes as well as positive feedback and
compliments.
Carer Communication
Due to the nature of the concerns within the Regulation 28 all carers have been sent
communications and guidance on when to call 999 in emergency situations and when to
contact 111. Examples of these will be incorporated in our induction and refresher training
and delivered by our in-house training team, who have been briefed on the incident to
ensure the topic is trained and discussed to a point where all new starters are clear on the
procedure. We have enhanced our spot check process and monitoring in the field will take
place by our Field Care Supervisors and Care Managers to continue testing knowledge
outside of a training room environment. An emergency and unexpected death of a client
policy has been introduced to the care delivery team.
The Trinity Group is committed to ensuring the health and safety of employees and clients
and by continuous improvement in our health and safety and environment standards. I hope
you find our actions satisfactory; we strongly believe this is an isolated incident and we have
taken relevant action.
Kind regards,
Chief Executive Officer | Trinity Homecare Group Ltd
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Direct:
Email: j
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