Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0341, written 13 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 | 13 Sep 2022 |
|---|---|
| Reference | 2022-0341 |
| Deceased | Peter Pearson |
| Coroner | James Puzey |
| Coroner area | Worcestershire |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
EX
REGULATD
28: !REPORT O PREVE
FUTURE DEATllil (1).
NOTE: This form is to be used aflileu' an Inquest.
28 RIEIPOliW VO PREVENT IFUTURIE
THO$ REPORT IS BEU G SEN'll' 'll'C:
·
1.
Cori»ati IHIWH Null'Blllil!J Heme, l!>rontwlch 81,H,
maeterelllllr&i
. 2.
3. Csrte QuaDlty CommDeelon;
4. Worceetarstnlre Cou Council.
1 CORO ER ·
I am James Puzey, assistant coroner, for the coroner area of Worcestershire
2 CORONER'S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the coroners and Justice Ad
2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
3
DNVESTIGA110N and R UEST
On 14 December 2021 HMSC David Reid commenced an Investigation into the death
of Peter Anthony Joseph Pearson, aged 78. The Investigation concluded at the end of
the Inquest on 19"' August 2022 which I heard. The conclusion of the Inquest was that
the medical cause of death was aspiration pneumonis and that Mr Pearson d!ed from
natural causes.
4 CIRCU STANCES CF THE DEA1lll
Mr Pearson died at the Worcester Royal Hospital on 8 December 2021 from aspiration
pneumonia. Prior to his admission he had been a resident at the Corbett House Nursing
Home, Droltwlch Spa ("the Home•) from 28 November 2021. Ha was admitted· to
hospital on 5 December 2021 In a aitic&I condition with erratic respiratory function and
multi-organ dlsfunctlon. He was known to suffer from moderate dysphagla mnongat
other conditions. The aspiration pneumonia was In all probability acquired whilst he was
resident at the Corbett House Nu~ng Home.
5 P RONER'& CONCERNS
During the course of the Inquest the evidence revealed matters gMng rise to concern.
In my opinion there Is a risk that future deaths wDI occur unless action Is taken. In the
ctrcumstsncas It Is my statutory duty to report to you.
The
TI'ERS Of ~ONCERN are ~s follows. -
(1) Mr Pearson's condition on 5 December 2021 was su~ that his daughter
asked the agency nurse on duty for an ambulance to be called at 12.30 pm•.
.
None was called until 6.10 pm. The nurse did not complete the nursing notes
.
.
1
for thSlt day from 5am onwards so there le no written record of Mr Pearson's
medical conditton that day. Mr Pearson was found by paramedics alone In his
room In a critir::llli state. The st&ff on duty knew very little about him or his
condition. The recx,n:I of medlr::llltlons dispensed to Mr Pearson that day h2s
been lost or is missing. He was found with medication In his mouth by
paramedics. No records were kept of the checks of his oral CS!Vlty that wara
required to be undertaken twice a day. The Agency nurse has not been
traced by the Home. The Inquest found es a fact that the fallure to call an
ambulance earlier amounted to a missed opportunity.
(2) The former Registered Manager of the home at the time of the death Is seld
by the Home's owner, to be responslbls for shortoomings In the management
of the home Including •providing false audit scams to senior management and
cherry picking ti/es which ware presented for lnspectlon.D It Is accepted by
senior management thait there were "shortcomings" in oversight of this
manager. The deputy manager (•llM") at the time of Mr Pearson's death has
now been promoted to Registered Manager despite the fact that her Job
description as OM Include responsibility for supervising and managing staff
and ensuring that all medications were recorded.
(3) It Is accepted on behalf of the Home that there was an "Ineffective
Investigation" into Mr Pearson's death by the Home. Responsibility for that
cannot not solely be attributed to the former Registered Manager.
(4) Whilst there have been changes to audit practice, Including the use of an
extemat auditor it Is not apparent that the overalght by senior management of
the Registered Manager or OM has changed materially. Nor is It apparent
what the current Registered Manager hes done to date to Improve record
keeping and record retention and the supervision of nursing staff ..
6 ACTION SHOULD IBE TAKEN
In my opinion action should be taken to prevent future deaths end I believe you and
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 9 Novembsr 2022. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting
out the ttmetable for action. Otherwise you musJ explain why no action le proposed.
8 COPIES and PUBLDCATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
I have also sent It to the care Quality Commission and
Persons:
Worcestershire County Council who may find it.useful or of interest.
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
fonn. 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 ttme of
your response, about the release or the publlcetlon of your response by the Chief
Coroner.
9
13 Septamber 2022
HMAC Jamas Puny
2
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