Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0294, written 26 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 | 26 Sep 2022 |
|---|---|
| Reference | 2022-0294 |
| Deceased | Robert Howell |
| Coroner | Lorraine Harris |
| Coroner area | East Riding and Hull |
| 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: Residential Manager, Elm Tree Court Care Home, 344, Preston Road, Hull, HU9 5HH And their overseeing management: HICA Group, Anchor Court, Francis Street, Freetown Way, Hull, HU2 8DT. 1 CORONER Lorraine Harris, Area Coroner, East Riding of Yorkshire and City of Kingston Upon Hull. 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 25th April 2022 I commenced an investigation into the death of Robert Norman HOWELL, age 91 years. The investigation concluded at the end of the inquest on 23rd September 2022. The conclusion of the inquest was: Narrative: Robert Norman Howell “Bob”, aged 91 years, was susceptible to falling. On 12th April 2022 in his room at Elm Tree Court care home Mr Howell fell backwards and banged his head sustaining a subdural haematoma. He was conveyed to Hull Royal Infirmary where he died on 20th April 2022. Cause of Death: 1a 2 Stenosis Subdural Haematoma Atrial Fibrillation, Severe left ventricular systolic dysfunction and Aortic 4 CIRCUMSTANCES OF THE DEATH Mr Howell have a history of falls and did not have capacity. In February 2022 he went to reside at Elm Tree Court care home. He had the relevant pre- assessment before admissions and had care plans devised when in the home. He suffered falls on 10th and 11th April 2022. Care staff for the night of 11-12th April 2022 were made aware of the fact he had fallen once on 11th, but not his 1 history of frequent falls. In the early hours of the 12th April 2022 his sensor mat activated, indicating that he had got out of bed. The carer attended and found him standing by his bed, he was naked. The carer was unsure why she did not firstly ask him to sit on the bed but she spoke to him and moved to his wardrobe to obtain clothing for him. As she did so he stumbled backwards and struck his head. An ambulance was called. He died in hospital from a subdural haematoma on 20th April 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 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. – (1) Team Leaders held handovers between themselves, it was then up to the individual Team Leader to decide what to pass on to the staff responsible for caring. It became apparent during evidence that often vital caring and risk needs were not always cascaded to the staff interacting with the residents. As such vital information to those responsible for providing care was often not provided. (2) Care plans were held in the office. Staff were not instructed to read the care plans. It was left to an individual carer to decide if they wished to seek out the care plan. No time was set aside for staff to familiarise themselves with the care plan or individual needs and risks of the residents. Vital information could therefore be missed by those responsible for providing care. (3) Evidence showed a lack of understanding about the falls policies in place. (4) It was acknowledged that the home did have procedures introduced since Mr Howell’s death however it became evident that there was still a breakdown in communication and vital information was not being shared. There appeared to be a lacuna in what information should be passed to all staff and how confirmation of understanding was checked. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 16th November 2022. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, 2 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: • (sister) as a representative of the family 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 other 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. 9 [DATE] [SIGNED BY CORONER] 26th September 2022 Lorraine Harris 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.
hica supporting better lives Heather Joy Director of Operations HICA Hesslewood Country Park Office Hessle HUB 0LH 1 Nov ,, c.'fJ22 The Coroners Courts & Office The Guildhall Alfred Gelder Street Kingston upon Hull HUl 2AA 11th November 2022. Report to Prevent Future Deaths Dear sirs Thank you for the correspondence and report to prevent future deaths in relation to the tragic death of Mr. Robert Norman Howell, who had been residing at Elm Tree Court Care Home, Hull. Humberside Independent Care Association (HICA) would like to respond with the comments and actions detailed below. The MATTERS OF CONCERN are as follows. (1) Team Leaders held handovers between themselves, it was then up to the individual Team Leader to decide what to pass on to the staff responsible for caring. It became apparent during evidence that often vital caring and risk needs were not always cascaded to the staff interacting with the residents. As such vital information to those responsible for providing care was often not provided. HICA Response. HICA has always had a process in place that formal handovers occur between shifts for staff. Staff should attend the handover meeting, but we did not have a system in place to record attendance at handovers. We have now introduced a standard handover template and attendance sheet into all services. In addition to this, we have introduced electronic care planning, whereby staff have access to up to date care plans, records, and risk assessments for each resident, at the point of care delivery. making a difference t. 01482 581000 w. www.hica-uk.com Humberside Independent Care Association Limited (Charitable Status) Anchor Court, Francis Street, Freetown Way, Hull HU2 SDT Company Registered Number IP27662R (2) Care plans were held in the office. Staff were not instructed to read the care plans. It was left to an individual carer to decide if they wished to seek out the care plan. No time was set aside for staff to familiarise themselves with the care plan or individual needs and risks of the residents. Vital information could therefore be missed by those responsible for providing care. HICA Response It has always been imperative for staff to read care plans of residents within services, and this has always formed part of induction training when staff commence induction into the workplace. We have now introduced electronic care planning, and staff hold devices which contain care plans on them during care, which means staff have information at the point of care delivery, which is contemporaneous. This is also supported by a change in the handover process, and the introduction of 'Flash' meetings in all services, which occur daily to provide any further updates to staff in regard to care support of residents during the shift. (3) Evidence showed a lack of understanding about the falls policies in place. HICA Response HICA has a falls policy in place, which is cognisant of information contained within NICE Clinical Guideline CG 161(Reviewed 2019)- Falls in older people: assessing risk and prevention. Our falls policy has been further reviewed and we are in the process of rolling out the use of the iSTUMBLE platform, which will be available on all handheld devices within our services. The app provides information to support staff on procedures to undertake when a resident has a fall. This will work in partnership with the falls policy and will is available at the point of care for staff to utilise. Alongside the falls diaries that are currently in place in services, we are also introducing weekly service falls meetings, which will review any falls incidents and ensure that risk assessments, and referrals if required have been complete and actioned. The addition of iSTUMBLE and the introduction of weekly falls meetings has been added to the reviewed falls policy, which will be rolled out to all services throughout November 2022. (4) It was acknowledged that the home did have procedures introduced since Mr Howell's death however it became evident that there was still a breakdown in communication and vital information was not being shared. There appeared to be a lacuna in what information should be passed to all staff and how confirmation of understanding was checked. HICA Response We have reviewed the concern noted in relation to communication and information sharing. The measures discussed in the previous three points have been introduced to aid the sharing of information and facilitate better communication. This will be supported by the continued use of staff supervisions. '1/!it. Sincerely Director of Operations, HICA
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