Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0385, written 25 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 | 25 Nov 2022 |
|---|---|
| Reference | 2022-0385 |
| Deceased | Ann Daghlian |
| Coroner | Elizabeth Dudley-Jones |
| Coroner area | North Wales (East and Central) |
| Category | Hospital Death (Clinical Procedures and medical management) 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.
Elizabeth Dudley-Jones
Assistant Coroner for North Wales (East and Central)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
TLC Nursing and Care
1
CORONER
I am Elizabeth Dudley-Jones Assistant Coroner for North Wales (East and Central)
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 22 November 2022 I commenced an investigation into the death of Ann Daghlain (DOB 12
November 1937 and (DOD 13 February 2021). The investigation concluded at the end of the
inquest on 24 November 2022 The conclusion of the inquest was a narrative conclusion as
follows :
Ann Daghlian came by her death on 13 February 2021 at 12.40 at Wrexham Maelor
Hospital from sepsis as a result of a sacral pressure sore, contributed to by metastatic
breast cancer. Ann was first diagnosed with metastatic breast cancer in 2017 and she
suffered spinal cord compression and as such she also had a permanent catheter. She had
lifelong chronic psoriasis. She had a package of care with carers from 2017 and regular
visits from District Nurses. At the end of 2020, her health had deteriorated - she had
received palliative radiotherapy, suffered weight loss and appetite difficulties. Her
mobility was once again affected and she began to decline an upstairs shower. Ann also
refused to undertake full body washing, such that it went unnoticed that a pressure sore
had developed on her buttock region. On 29 January 2021, a carer noticed a redness to
Ann's buttocks and thereafter, her family and District Nurses were informed. District
Nurses appropriately attended to the pressure sore and dressing it until 9 February 2021,
whereupon it was decided that it had deteriorated to the point of hospital admission. Ann
was admitted to Wrexham Maelor Hospital on 9 February 2021, but she deteriorated
despite clinical efforts and she died on 13 February 2021.
4
CIRCUMSTANCES OF THE DEATH
The circumstances of the death are as follows :
As detailed in the above narrative conclusion
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. –
I heard evidence that despite it being recorded and noted by carers that (notwithstanding their
efforts to persuade) that there was clear deterioration in terms of the deceased refusing to
shower and/or receive full body washing, that there was no formal review system in place at TLC
nursing and care which would trigger a request to the local authority (or other appropriate
authorities) to request a formal review of those concerns. A formal review request would then
have involved a multi disciplinary meeting of various other professionals to consider risk, whether
or not the care user had capacity.
TLC nursing and home care have no mechanisms in place currently (or planned in the future)
which properly monitor care provision to ensure that their care plan is infact being met or if it is
not being met.
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.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely 23
January 2023. I, Elizabeth Dudley-Jones, 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 Family of the Deceased and to the Chief Coroner.
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 25 November 2022
Signature
Assistant Coroner for North Wales (East and Central)
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.
TLC Nursing & Homecare Plus.
60 Pen Y Bryn,
Wrexham.
LL13 7HY.
TLC Nursing and Homecare Plus Ltd. Response to Regulation 28 Report from
The Coroner
Following the coroner’s report outlining the absence of a formal review system that would trigger a request to
appropriate authorities – despite it being recorded and noted (notwithstanding the carers effort to persuade) that there
was a clear deterioration with regards to the deceased refusal to shower and/or receive a full body wash; TLC Nursing
and Homecare Plus has implemented a number of measures to better monitor the care provision, reduce risks, assess
mental capacity and ensure that any deviations to the care plans are quickly and efficiently addressed.
These measures include and are not limited to:
staff training
introduction of an automated review system
•
•
• more regular client review process
Staff Training
TLC management is currently performing a training needs assessment review for all staff, any carer that is identified
as requiring additional training has been prioritized to complete their training by end of Feb 2023.
As a company we have also included mental capacity, risk assessment and pressure area care courses in the
mandatory training list, this will help minimise the risk of self-neglect. We aim to complete all mandatory training for
all the staff by the end of June 2023.
This training will help as follows:
1. Mental Capacity Training (MCA) will help staff understand how to support individuals to make their
own decisions and manage their own care, where possible. This will reduce the risk of self-neglect
by empowering individuals to take control of their own care and make informed decisions about their
health and wellbeing.
2. Risk assessment training will help staff identify potential risks and hazards in the environment and
develop strategies to minimise or mitigate those risks. This will include risks related to the client’s
physical and mental health, as well as risks related to the home environment. By identifying and ad-
dressing these risks, staff will help reduce the risk of self-neglect.
3. Pressure area care will help the staff to identify the individuals at risk of developing pressure sores
and take steps to prevent them from occurring. This will include using specialised equipment, such
as pressure-relieving mattresses and cushions, and regularly checking and repositioning individuals
to prevent the development of pressure sores. Preventing pressure sores will help reduce the risk of
self-neglect.
This training will be mandatory for all staff, working alongside the local authority to design and deliver courses which
will address the early detection of self-neglect. This training is now updated on the TLC training matrix and will be
reviewed annually by the manager.
Automated Review System
TLC has also invested in an automated system (Birdie App) to assist with quickly triggering a review into a client’s
risk and capacity or changes required in their care plan. This system is designed to identify any potential concerns
about a client’s care or well-being and automatically initiate a review system.
It works as follows:
1. Continuous monitoring: this new automated system enables TLC to continuously monitor a client’s
care and well-being, alerting the management team to any changes or concerns that may arise. This
will help to identify potential issues more quickly than when the Management team were relying on
manual checks and reports.
2. Quicker response times: a review process will be initiated as soon as a potential concern is identified.
This will help to ensure that any necessary action is taken in a timely manner.
3. Improved accuracy: this system will help ensure that relevant information is accurately captured and
that any necessary actions are taken based on this information. This will help to prevent errors or
omissions that could potentially impact the care and well-being of the client.
Once concerns are identified, a formal review will be requested promptly which should involve carers and other
relevant professionals, such as social workers, DNs and GPs to ensure that the full spectrum of needs is being met.
Reviews should be documented, and any action taken is also documented.
More Regular Client Review Process
TLC normally carry out formal reviews with all clients 3 monthly, however, with immediate effect formal review
process will be triggered sooner when a concern is raised. The review will involve performing a risk assessment and
mental capacity of a client and potentially trigger a request to relevant authorities for further assessment and support
when concern is raised.
Steps to be taken to implement a formal review will be as follows:
1. Identify the need for a formal review: this may be due to changes in the client behaviour, physical or
mental health , or other concerns that have been raised by the carers.
2. Gather relevant information: This will include reviewing the clients care plan and any recent assess-
ment or reports as well as consulting with other professionals involved in the clients care.
3. Involve the client in the process: The client will be involved in the process to ensure that their views
and preferences are taken into account.
4. Assess the clients risk and mental capacity: Based on information gathered the care team will assess
the clients risk of harm and determine whether they have the mental capacity to make decisions
about their own care and support.
5. Make a recommendation to the relevant authorities: If the formal review indicates that the client is at
risk of harm or lacks the mental capacity to make decisions about their own care, TLC will make a
request to relevant authorities for further assessment and support.
Conducting a formal review will be an important step to ensure that the well-being and safety of our clients is
maintained . By gathering relevant information, involving the client in the process, and making recommendations to
relevant authorities where necessary , we will ensure that the clients receive the support and care they need to live
fulfilling and safe lives.
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.