Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0276, written 6 Sep 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Sep 2022 |
|---|---|
| Reference | 2022-0276 |
| Deceased | Frances Ollis |
| Coroner | Ian Arrow |
| Coroner area | Plymouth, Torbay and South Devon |
| Category | Other 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.
OFFICIAL Ian M Arrow Her Majesty’s Senior Coroner for the County of Devon Plymouth, Torbay and South Devon Coroner Service REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chair, Integrated Care Commission, NHS Devon, County Hall, Topsham Road, Exeter, EX2 4QD 1 CORONER I am Ian Arrow, Senior Coroner for Plymouth Torbay and South Devon 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 Inquest opened 10th March 2022 Inquest heard 5th September 2022 4 CIRCUMSTANCES OF THE DEATH The deceased suffered from debilitating conditions, she lived in insanitary conditions. Help was called for her on the 21st of February 2022. A safe guarding referral was made. She suffered a long lie on the night of 23rd of February. A second visit to the deceased on the 24th of February found the deceased in extremis. She had developed sepsis. She died at Torbay Hospital on 25th of February 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) On the balance of probability there was a missed opportunity to afford timely care and treatment to the deceased before she was found in extremis on the 24th of February 2022. OFFICIAL 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. Please review the protocols in Devon for dealing with individuals whose personal care and personal hygiene is inadequate due to their known personal circumstances particularly when this presents as a foreseeable risk of infection. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Monday 31 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. I have also sent it to interest. who may find it useful or of 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 06/09/2022 Signature
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.
Ian M. Arrow H.M. Coroner Derriford Business Park Plymouth PL6 5QZ 18 October 2022 Dear Mr Arrow Chief Nursing Officer NHS Devon County Hall Topsham Road Exeter EX2 4QD NHS Devon Action Plan to address Regulation 28 in relation to the death of FKO Review of the protocols in Devon for dealing with individuals whose personal care and personal hygiene is inadequate due to their known personal circumstances particularly when this presents as a foreseeable risk of infection. Regulation 28 Request from the Coroner A range of health and social care agencies provide care to people whose personal care and personal hygiene may be inadequate. This lack of personal care is described in the Care Act guidance as self-neglect and covers a wide range of behaviour such as neglecting to care for one’s personal hygiene, health or surroundings and includes behaviour such as hoarding. Details about what constitutes self-neglect, and the actions practitioners should take should be outlined in safeguarding adult policies. Health and social care staff receive regular safeguarding training to improve their knowledge and competence. This training is delivered in a variety of ways including face to face sessions, e learning packages, webinars, newsletters, and briefings. NHS Devon Integrated Care Board (ICB) is responsible for commissioning health services in Devon. It works in collaboration with NHS trusts, GPs, local authorities, and a range of agencies such as the voluntary and independent sector to form an integrated care system (ICS) known as One Devon. NHS Devon ICB has reviewed its own safeguarding adult policies and has asked the safeguarding leads of those services that it commissions to review and update, if necessary, their safeguarding policies. A learning brief has been developed and disseminated to NHS commissioned healthcare providers to inform staff of this case and to support staff to understand that a lack of personal care and hygiene (including oral hygiene) can impact upon a person’s physical health and wellbeing and can lead to infection and sepsis; and to promote the recognition and support of those individuals who are unable to maintain their personal hygiene to manage the potential risk of infection and sepsis. NHS Devon Commissioned Services NHS Devon ICB NHS Commissioned Health Services Safeguarding Adult Policy reviewed and amended Letter sent to request review and amendment of relevant policies and confirmation of review and outcome by 7th November 2022. NHS Devon Head of Safeguarding will ensure that assurance is received from providers. Letter sent to request review and amendment of relevant policies by 7th November 2022. NHS Devon Head of Safeguarding will ensure that assurance is received from providers. Independent Commissioned Health Services General Practice NHS Devon ICB has delegated commissioning responsibility for General Practice services in Devon and provides safeguarding support to GP practices. Each practice is responsible for their safeguarding policies. Many use the Royal College of General Practitioners (RCGP) safeguarding adult policy template. Primary Care Safeguarding Adult Policies RCGP Safeguarding Adult policy reviewed by Primary Care Safeguarding Named Nurse.29/09/22. Amendment required. Letter sent to request review and amendment of relevant policies by 7th November 2022. NHS Devon Head of Safeguarding will ensure that assurance is received from Practices. Communication will be included in GP Bulletin and Devon LMC (Local Medical Committee) newsletter and learning from this case will be discussed at the regular fora held with GP Safeguarding Leads Safeguarding Adult Partnerships. As a partner of the two safeguarding adult partnerships in Devon; Torbay and Devon Safeguarding Adult Partnership (TDSAP) and Plymouth Safeguarding Adult Partnership (PSAP), NHS Devon will present the learning from this case and the need to ensure that multiagency safeguarding adult policies and adult social care policies are reviewed and updated, and changes disseminated to health and social care staff across the safeguarding partnerships. NHS Devon Head of Safeguarding will take a paper to the next Partnership meetings. Action Paper to PSAP Paper to TDSAP Date of Partnership Meeting 13/10/22 13/12/22 I hope the above action plan adequately outlines the action taken or planned to be taken by NHS Devon to meet the Regulation 28 report to prevent future deaths issued’. Yours sincerely 2
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