Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0384, written 28 Nov 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Nov 2022 |
|---|---|
| Reference | 2022-0384 |
| Deceased | Janice Hopper |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| 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 REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: WINDMILL HOUSE CARE HOME owned by RUNWOOD HOMES SENIOR LIVING 14 Browick Road Wymondham Norfolk NR18 0QW 1 CORONER I am Jacqueline LAKE, Senior Coroner for the area of Norfolk 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 21 February 2022 I commenced an investigation into the death of Janice HOPPER aged 74. The investigation concluded at the end of the inquest on 17 November 2022. The medical cause of death was: 1a) 1b) 1c) 2) Alzheimer's Dementia Chronic Kidney Disease, Type 2 Diabetes Mellitus The conclusion of the inquest was: Natural causes 4 CIRCUMSTANCES OF THE DEATH Mrs Hopper was discharged from hospital to Windmill House Care Home on 31 December 2021. On 14 January 2022, Mrs Hopper's condition deteriorated and emergency services were called. Mrs Hopper was taken to the Norfolk and Norwich University Hospital where she was diagnosed with reduced consciousness and hyperglycaemia. She had evidence of acute kidney injury. With treatment Mrs Hopper's condition improved and she was being considered for discharge. Her condition then deteriorated and she died on 12 February 2022. Regulation 28 – After Inquest Document Template Updated 30/07/2021 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: 1. Mrs Hopper had dementia. The Care Plan was not prepared with input from Mrs Hopper's husband. 2. Evidence was heard that some information in the Care Plan purporting to relate to Mrs Hopper was "cut and paste" from another resident's Care Plan. 3. The Care Plan contained several inaccuracies such as referring to Mrs Hopper as a "man" and saying she enjoyed taking her meals in the communal dining room, when she was confined to her room due to Covid 19 isolation. 4. The Care Plan provided for Mrs Hopper to be weighed weekly. She was not weighed weekly. 5. Mrs Hopper was diagnosed with Diabetes. The Care Plan provided for Mrs Hopper's blood sugar levels to be checked twice weekly. This information differed from information contained in other documents. Mrs Hopper's blood sugar levels were not checked until the day she presented as unwell and was admitted to hospital, some fourteen days after admission. 6. The Care Plan provided for Mrs Hopper to be on a controlled diet due to her diagnosis of Diabetes. Evidence was heard this meant "low sugar" and staff were made aware of this orally. There was no record of any specific diet relating to Mrs Hopper or to a resident with a diagnosis of diabetes. 7. Due to concerns about Mrs Hopper's intake of fluid, there was a recommended daily fluid intake. The amounts of fluid given to Mrs Hopper and the amounts she drank were estimated by staff. 8. The amount of fluid intake was not always recorded in the notes by the staff who had estimated the amount consumed but relayed to another member of staff who would complete the records. 9. There were concerns about Mrs Hopper's food intake. It is not clear from the evidence that the amount stated in the records as being consumed was accurate. For instance, on several occasions she was noted to have consumed large amounts of fluid in one go and to have eaten more than one meal within a short space of time. 10. Mrs Hopper was discharged from hospital with medication including Morphine Sulphate. The written instructions were she was to be given a dose four times a day "as and when required". Mrs Hopper was given seventeen doses of Morphine Sulphate as a matter of course, regardless of whether this was required, before this was stopped by a General Practitioner. 11. Care Plans are not regularly reviewed or audited by senior members of staff. 12. An internal investigation carried out by the Care Home recommended review of Fluids and Nutrition be audited regularly and a "lessons learnt" document would be created for all staff. There is no evidence that these steps have been taken. Regulation 28 – After Inquest Document Template Updated 30/07/2021 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I 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, namely by January 20, 2023. 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: – husband I have also sent it to: Care Quality Commission (CQC) Healthwatch Norfolk 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: 28/11/2022 Jacqueline LAKE Senior Coroner for Norfolk County Hall Martineau Lane Norwich NR1 2DH 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.
Runwood Homes PLC Windmill House 14 Browick Road Wymondham Norfolk NR18 0QW 19 January 2023 Dear Her Majesty’s Coroner Re: Prevention of future deaths report – Windmill House. Care plans being prepared without input from family. New pre admission form has been developed and now includes detailed information regarding resident and family input, all pre admissions will be completed in person and not over the phone, families will be involved as part of the pre-admission process irrespective of resident capacity as long as the resident with capacity consents, this will be documented on the form. New residents’ risk assessments will be completed in co-ordination within 24 hours and care plans within 7 days, although priority will be given within the first 6 hours to the highest risks to residents, e.g. choking, falls, pressure ulcers, evacuation during a fire, nutrition/hydration and any other specific ones such as pain, epilepsy, diabetes, moving and handling, absconding. This will allow staff to be able to assess the resident and gain further knowledge of their needs. All families will be invited to attend after 6 weeks to review these and then sign, these will be followed up monthly during the “Resident Of The Day” process and a full review will be undertaken at 6 months of the resident’s care plan and risk assessments, or if needs change they will be reviewed sooner. Care plans being developed through cutting and pasting from other residents care plans. All care staff have now completed further training on the electronic care plan system, all care staff are fully trained in making sure care plans are developed for the individual and nothing is to be copied and pasted from others’ care plans. This is being regularly reviewed by the senior team through auditing, and reviewed again monthly during the resident of the day process. Care plans containing several inaccuracies. Again through a thorough pre admission assessment and training delivered on developing person centred care plans, any potential for inaccuracies is being closely monitored by the senior team as documented above. All new residents admitted to the home are being weighed weekly for the first 4 weeks of their stay, this allows us to monitor residents’ dietary needs closely and to ensure that these are being met, and to assess whether any further input is needed from multi-disciplinary teams. Developing care plans for residents with a diagnosis of diabetes Further to the inquest, all residents with a diagnosis of diabetes, whether it be tablet or diet control, are now having their blood sugars monitored via the GP practice and these residents are having their bloods taken every 3-6 months. All care plans are now person centred to the individual with how staff should respond to a resident who maybe experiencing hypo/hyperglycaemic episodes, and they better reflect the residents dietary requirements. As part of the process of reviewing care plans for residents with diabetes, advice was obtained from the catering and hospitality lead, who also worked closely with a nutritionist on the menus for the care home, which included advice related to menus for residents with diabetes. These menus are now discussed at the monthly nutritional meeting with the senior staff and head chef, these meetings are minuted and given to the teams, including the kitchen, to ensure that the information is well communicated. Concerns over fluid intake and how this was monitored and documented. All residents’ care plans are developed with the individual, information gained from the residents’ pre admission assessment and information gained from the resident and their family allows us to gain information regarding what their fluid intake has been like and also through fluid charts for the first four weeks, allows us to monitor fluid intake. Hydration trolleys are in effect at the home, one each shift one person is allocated to be responsible for ensuring that residents’ fluid intake is monitored and documented accurately. This was discussed at the care plan training and how to accurately record fluid intake. All staff are required to ensure that they record intake in milliltres, “mls” in all entries so that the electronic care record system automatically picks up the intake and calculates it. Fluid intake is monitored daily by the Care Team Leader (CTL) with a further overview by the Deputy Home manager. The care team are reporting to the senior team any concerns relating to residents’ fluid intake. Staff determine residents’ fluid intake by the size of the cup in mls, how much has been offered and then drank. PRN medication not given as stated on the discharge letter from the hospital All senior care staff have to record all medication received into the home and two staff are required to check and sign in medication on the medication administration record (MAR) chart. This follows the medication policy and procedure, any concerns over documentation when a person is discharged from a hospital are followed up with the hospital, and if admitted from the community, the resident’s GP will be contacted to confirm any queries with prescriptions. All as required (PRN) medication has a protocol produced that is person centred. For any resident that has a cognitive impairment and is unable to verbalise pain, staff will assess whether they are or are not in pain by using facial expressions, body language or a pain assessment tool to gain this information and act on the information obtained. PRN medications are documented in the residents care plan, along with regular medication, so all senior staff that are medication trained will have this knowledge when administering medication, all senior staff have been completing extra medication training to develop their skills. Care plans not being audited and reviewed by senior team A percentage of care plans are being audited monthly, the Regional Director and deputy home manager, review care plans monthly as part of the “Resident Of The Day” process. Staff are ensuring that all care plans are accurate and person centred and individualised to residents’ personal needs. Lessons learnt have been completed and reviewed, regular staff and care team leaders meetings have been held to communicate these changes, and also 1:1 supervisions have been held. Lessons learnt no evidence of implementation and nutrition/hydration records not regularly audited. Any findings from concerns raised have a lessons learnt in place, these are then discussed at flash meetings, 1:1’s if applicable, and given to the team to read and sign. Food/fluid charts are being reviewed daily by the CTL, any concerns are then discussed with the team at handover and fed back to them, the CTL also reviews the electronic care record system to ensure that this is being recorded effectively and accurately. Any concerns that this is not being followed is raised to the deputy home manager and communicated back to the Regional Director. Yours Sincerely, Regional Director
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