Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0254, written 12 Aug 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 Aug 2022 |
|---|---|
| Reference | 2022-0254 |
| Deceased | Gerald Tuck |
| Coroner | Rachael Griffin |
| Coroner area | Dorset |
| 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 (1) NOTE: This form is to be used after an inquest REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. , Managing Director of Tricuro 1 CORONER I am Rachael Clare Griffin, Senior Coroner, for the Coroner Area of Dorset 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 15th On the Gerald Kenneth Tuck, born on the 17th June 1931. March 2022 an investigation was commenced into the death of The investigation concluded at the end of the Inquest on the 11th August 2022. The Medical Cause of Death was: la Pneumonia lb Immobility due to traumatic head injury le II Frailty Diabetes Cerebrovascular disease, Atrial Fibrillation, Dementia, Hypertension The conclusion of the Inquest was "Accident" 4 CIRCUMSTANCES OF THE DEATH The deceased, who suffered with dementia, became a resident at Sidney Gale House Residential Home, Bridport in January 2017. On the 25th December 2021 he fell at the home and was admitted to Dorset County Hospital, Dorchester. A CT scan did not reveal any head injury and he was subsequently discharged back to the home on the 27th December 2021. There is no record of a review of his falls risk assessment following his return. He was found on the floor in the home on the 27th January 2022 but was not thought to have sustained any injury. That day he was prescribed antibiotics for a suspected urine infection. There is no record of a further review of his falls risk assessment. On the 28th January 2022 he was found on the floor in his bedroom at the address and had bruisinq and a lump to his forehead. He was taken to Dorchester Cou nty 1 Hospital where a CT brain scan revealed he had sustained 2 acute subdural haematomas. His condition deteriorated and he was discharged back to Sidney Gale House Residential Home on the 22nd February 2022 where he died on the 2nd March 2022. 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: 1. During the Inquest evidence was heard that: i. ii. Sidney Gale House Residential Home is governed by Tricuro Limited Upon a person becoming a resident at the home, a care plan is put in place which requires a number of risk assessments to be undertaken. These risk assessments, and the care plan, are reviewed monthly. If there is an incident, such as a fall, the expectation is for the care plan and the risks to be further reviewed, however there is no formal policy, procedure or guidance document in place covering this. iii. On the 25th December 2021 the deceased fell at the home and was taken to hospital. He was discharged on the 27th December 2021. He fell again on the 27th January 2022 and again on the 28th January 2022 when the fatal injury was sustained. iv. The Registered Manager of Sidney Gale House gave evidence that his last falls risk assessment is documented to have taken place on the 16th December 2021. There is no evidence one was completed after this prior to the fatal fall on the 28th January 2022. The monthly review was due on the 31st January 2022 and there was no assessment recorded after the falls on the 25th December 2021 and 27th January 2022. 2. I have concerns with regard to the following: i. There is no written policy or guidance in place at Sidney Gale the review of care plans House Residential Home around following an incident at the home and this could lead to a future death is necessary risk assessments are not undertaken following an incident occurring. 6 ACTION SHOULD BE TAKEN In my opinion urqent action should be taken to prevent future deaths and I 2 believe you and/or 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, 7th October 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: (1) Mr Tuck's family I have also sent a copy of my report to the following people who I believe have a sufficient interest in the contents of it: Care Quality Commission 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 Dated Signed 12th Au ust 2022 Rachael C Griffin 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.
Official To: Rachael Griffin Tricuro Tricuro Head Office 0 Beech House 28-30 Wimborne Road Poole Dorset BH15 2BU & e www.tricuro.co.uk 7th October 2022 Dear Rachael, I write in response to your letter relating to a person who resided in one of our services, we have carefully reviewed this event to ensure that this does not happen again and that we have sufficient policy and procedures within Tricuro to inform all staff as to what they need to follow. Background information: Mr Gerald Tuck (known as Gerry) Sidney Gale House, Flood Lane, Bridport, DT6 3QG Gerry was admitted to Sidney Gale House Residential Home on 15th January 2017. On admittance a care plan commenced and added to and changed over time due to differing needs and outcomes. All care plans are reviewed on a monthly basis with input from the resident, carers and family. Waterflow etc Gerry required assistance with maintaining all aspects of personal care throughout the day and night. Gerry was able to mobilise independently with the use of a Zimmer frame, he chose to spend all his time in his room including mealtimes. At night a sensor mat was used to alert staff to Gerry getting out of bed as frequently throughout the night he would be sat on the edge of his bed. Gerry had the daily paper delivered. At times it was hard to converse with Gerry due to his loss of hearing and staff would write things down for him to read. Gerry lived with the following health conditions Type 2 Diabetes - Insulin administered daily Glaucoma Essential hypertension Atrial Fibrillation Mixed Dementia Sensorineural hearing Loss Allergy to Trimethroprim, erythromycin and mepore A DNAR was in place The Care Company Wholly Owned by Dorset Council and Bournemouth, Christchurch and Poole Council (BCP) Tricuro Limited (09536732) and Tricuro Support Limited (09536638) Beech House, 28-30 Wimborne Road, Poole, Dorset, BH15 2BU Registered in England and Wales L0027 I have broken down our response and actions to each area: The 25TH of December 2021 - Gerry fell in his room The service did follow the falls policy and call for an ambulance as it was an unwitnessed fall, and he takes warfarin. Gerry also said he had hit his head. Post fall observations were taken until the ambulance arrived and admitted Gerry into Hospital. When he returned to the service he returned with antibiotics for an infection, and the staff updated his medications, and monitored his health and wellbeing. On review of his notes, I can see staff frequently checked on Gerry and updated his body map to reflect a skin tear from the fall that the District Nurse was tending to. However, what should have happened is that his care plan and risk assessments were reviewed and updated following his arrival back into the service. On the 26th of January 2022 Gerry was visited by the GP due to him being unsettled in behaviour and more confused, the GP prescribed some antibiotics and suggested a trial of Memantine. I can see staff recorded checking on him frequently. On the 27TH of January 2022 Gerry had an unwitnessed fall, they stated no injuries, and they did commence post falls monitoring to observe for any deterioration and did not note any. However, given that he takes warfarin the protocol should have been to contact the ambulance service to assess, and his care plans and risk assessments should have been updated. On the 28th of January 2022 Staff contacted the GP as they felt he was more confused than normal and were awaiting antibiotics to be delivered, they called the GP to chase the medications. Sadly, he later fell and had clearly injured himself as staff observed some blood on the fall and they followed policy by calling for an ambulance. Our Falls policy does state the need to use the post falls assessment tool and had this have been used and followed accordingly following his fall on the 27th ot January 2022 the staff would have been guided that as he takes warfarin medical assistance should be sought. To mitigate further risks we have uploaded the post falls assessment tool to the electronic recording system that is used to ensure staff do see, follow and record on this. The falls policy has been reviewed and updated to reflect the need of anticoagulant recognition and escalation following an fall. The Care Com pany Wholly Owned by Dorset Council and Bournemouth, Christchurch and Poo Cou nciI ( BCP) Tricuro Limited (09536732) and Tricuro Support Limited (09536638) Beech House, 28-30 Wimborne Road, Poole, Dorset, BH 15 2BU Registered in England and Wales Our policy also reflects that staff are expected to update the falls risk assessments and mobility care plans after any fall to ensure that the care, support and risks are managed accordingly. We have ensured that all staff within the service and the wider company are very clear of the policy and that this must be followed. Tricuro have also now introduced a live accident and Incident reporting system, this means that any falls or other accidents or incidents are directly available for our quality assurance teams to see, our locality team and the registered managers. This means that we can instantly check that the service has carried out all of the necessary actions in response to events and that the persons support plan and risk have been actioned. We also have created a policy and procedure for any deaths in service which details the need to investigate any unexpected deaths, this will prevent us from being unaware at head office of anyone who sadly passes away. Death reports are now reported internally to Head Office which means we can review all reports to ensure that deaths were handled appropriately but also to ensure that the care and support prior to this was as it should be. Services are ensuring that falls are monitored within service level and any root cause analysis learnt or is completed and actioned as needed, managers share any recommendations with other services. lessons Furthermore, we have falls focus group which means we are able to keep staff updated and reiterate the falls policy process and importantly how to reduce the risk of falls . Tricuro also now have a monthly safeguarding and accidents/incident report that is presented at Senior leadership meetings for scrutiny and review. I hope this provides you with the assurances you need relating to this event and to prevent and mitigate any future risks. Please do let me know if you require any additional information. ) J Yours sincerely Executive Director of Operations The Care Com pany Wholly Owned by Dorset Council and Bournemouth, Christchurch and Poo Cou nciI ( BCP) Tricuro Limited (09536732) and Tricuro Support Limited (09536638) Beech House, 28-30 Wimborne Road, Poole, Dorset, BH1 S 2BU Registe red in England and Wales
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