Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0076, written 27 Feb 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Feb 2023 |
|---|---|
| Reference | 2023-0076 |
| Deceased | Peter Seaby |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: The Oaks and Woodcroft Care Home 2a Dereham Road, Matishall Dereham, NR20 3AA The Priory Group (Owner) 1 CORONER I am JACQUELINE LAKE HM Senior Coroner for the coroner 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 06 July 2022 I commenced an investigation into the death of Peter Gary SEABY aged 63. The investigation concluded at the end of the inquest on 24 February 2023. The medical cause of death was: 1a) 1b) 1c) 2) Aspiration Pneumonia Down's Syndrome, Cirrhosis of the Liver, Cerebral Infarction. The conclusion of the inquest was: Mr Seaby died of aspiration pneumonia. Inadequate preparation of his lunchtime meal and inadequate supervision at his lunchtime meal possibly contributed to his death 4 CIRCUMSTANCES OF THE DEATH Peter Seaby was a resident at The Oaks and Woodcroft Care Home. Mr Seaby was assessed by a Speech and Language Therapist [“SALT”]. A SALT Care Plan was in place with regard to his nutrition which included specific requirements that he be given only soft, moist and mashed food, with two specific exceptions and that he was to be supervised throughout meals on a one-to-one basis with a ten minute gap between food and drink and for ten minutes afterwards. The Care Plan stated it was “essential” the Plan was adhered to and specifically provided that if the requirements were not adhered to, Mr Seaby was at risk of aspiration and asphyxiation “which are potentially life threatening”. Evidence was heard that Mr Seaby was not always given food which complied with the Care Plan and he was not Regulation 28 – After Inquest Document Template Updated 30/07/2021 always provided with supervision in compliance with his Care Plan. On 21 May 2018, Mr Seaby’s food at lunchtime was not prepared in accordance with the SALT Care Plan. Mr Seaby was not provided with the required one to one supervision during the lunchtime meal. During lunch Mr Seaby coughed while eating and brought some food back up. He cleared his throat and then appeared fine and finished the rest of his meal. At afternoon snack Mr Seaby brought up large amounts of phlegm and then coughed up anything he ate or drank. Mr Seaby was taken to see the General Practitioner by a member of staff who had not been with Mr Seaby during that day. No copy of Mr Seaby’s Daily Record was shown to the General Practitioner. Mr Seaby was given a working diagnosis of gastric reflux and his medication was changed. At teatime, Mr Seaby coughed/vomited his medication and yoghurt and drink. Mr Seaby vomited phlegm on two more occasions. The 111 service was called at 20.53 hours. The out of hours Doctor was spoken to at 22.45 hours following which emergency services were contacted and Mr Seaby was taken to Norfolk and Norwich University Hospital where he died on 22 May 2018. Following post mortem examination a slice of carrot was found in Mr Seaby’s throat. 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. Many steps have been taken in the period following Mr Seaby’s death. However there remain areas of concern The MATTERS OF CONCERN are as follows: 1. Evidence was heard at the inquest of the “informal approach” taken with regard to arrangements as to who would provide supervision of residents, including on a one to one basis and who would cook and prepare their meals, including those residents who were subject to a specific SALT dietary plan. Evidence was also heard of steps which have been put in place since Mr Seaby’s death to provide written staff rotas for such matters, prepared by Team Leaders and Deputy Managers. However, despite these steps being taken, evidence was also heard at the inquest from staff, who continue to provide care at Oaks and Woodcroft Care Home, referring to providing care on an “informal basis” and that this “works”. It was not clear from the evidence that the staffing levels at Oaks and Woodcroft Care Home are sufficient to provide care for residents, including those requiring one to one supervision and supervision out of the Home and to cover individual activities 2. 3. Mr Seaby died in 2018 and this is the second inquest into Mr Seaby’s death. There has still been no internal review carried out following Mr Seaby’s death which was unexpected. No Manager was present throughout the inquest and when some elements of evidence were put in dealing with Regulation 28 matters there was some surprise at some of the points raised and evidence heard during the course of the inquest. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action. Regulation 28 – After Inquest Document Template Updated 30/07/2021 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by April 24, 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: represented by Hodge Jones & Allen, solicitor, Serjeants Inn, counsel NCC represented CQC represented I have also sent it to 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: 27/02/2023 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.
Chief Executive Officer Priory Monday 24 April 2023 Ms Jacqueline Lake Senior Coroner for Norfolk County Hall Martineau Lane Norwich, NR1 2DH Private and Confidential Dear Ms Lake, Peter Gary Seaby - Response to Regulation 28 Report I write to you in response to the Regulation 28 Report dated Monday 27 February 2023. The report was issued following the Inquest touching the death of Mr Peter Seaby. You have raised two matters of concern that directly relate to The Oaks and Woodcroft Care Home and a further matter of concern relating to an aspect of governance within Priory Adult Care. The responses to the matters of concern are as follows below. Please note that each concern has been raised and discussed directly with the management team at the home in order for them to reflect on the issues and take appropriate remedial actions. 1. The provision of care You have raised a concern that staff operate an informal approach in respect of the delivery of care to residents at the home. Priory Adult Care’s Director of Quality outlined in Inquest You will note that statement the enhancements that have been put in place at The Oaks and Woodcroft Care Home. The enhancements include: Having in place person centred support plans, handovers and one-page resident profiles. Arrangements to promptly report and review each incident and ‘near-miss’ incident. Systems to identify areas of improvement and lessons learned in response to incidents and ‘near- miss’ incidents. An overarching policy: OP47 Supporting Service Users with Swallowing Difficulties (Dysphagia) which is supplemented by a summary of the policy and ‘flash’ cards made available to staff at the home. Detailed individual resident swallowing / choking risk assessments. Systems to ensure robust handovers between outgoing and incoming shifts. Arrangements to ensure that residents are escorted to appointments with experienced staff who know the particular resident. A process for inducting and training colleagues with reference to the International Dysphagia Diet Standardisation Initiative (IDDSI) framework. Competency assessments to be completed by staff to ensure that they can articulate the resident’s support needs and observation levels. An internal training team of experts to deliver emergency first aid at work training to colleagues across Priory Adult Care. This has helped to ensure that staff consider the risk of choking and the practical measures that can be put in place to reduce the risk. The introduction of ‘Nourish’, a bespoke electronic care records system enabling colleagues at the home to have quick and easy access to resident profiles and support plans. Nourish also assists the management team to check that effective support plans are in place. Registered Office: Priory, Fifth Floor, 80 Hammersmith Road, London, W14 8UD There is an experienced and knowledgeable management team in place at The Oaks and Woodcroft Care Home. The team are supported by an effective central divisional management and compliance team who maintain a detailed oversight of the home and resident safety and welfare. Our view is that the home continues to operate safely and the residents are well cared for and supported. We were however disappointed to learn that a witness, a current member of staff, gave evidence of care being delivered to residents in an ‘informal’ manner, despite the significant measures that we have in place at the home, some of which are listed above. meant Since the Inquest we have offered support to the staff member and explored with her what by the term ‘informal’. We have asked her to identify the areas of day-to-day practice that feels would benefit from being made more precise. More widely, the staff team as a whole have been given feedback, as part of the debrief process, on the outcome and learning from the Inquest and have been asked for their views on resident care and what, if any, improvements need to be made. This exercise has resulted in some additional improvements having been made in terms of the process for allocation of roles, staff understanding their roles and responsibilities particularly at mealtimes and the process for staff handovers has been strengthened. We will continue to consult with, listen to and respond to staff at the home using, for example, the supervision process, staff meetings and colleague engagement surveys and continue to develop the service where improvement opportunities are identified. 2. Staffing levels Our operational management team, together with the home management team, regularly review staffing levels at each of our homes, for example prior to the admission of a new resident and in response to the deterioration of a resident’s health. The operational management team have taken this opportunity to review staffing numbers again in response to your report, by consulting with the home management team, seeking feedback from colleagues at the home and reviewing resident support plans and considering resident needs. We are satisfied that staffing levels at The Oaks and Woodcroft Care Home are satisfactory, that staff are being effectively allocated to care for residents and that staffing numbers are sufficient to ensure that residents are safe and well looked after. On a practical level, meal times are now undertaken in two sittings to enable closer supervision of each resident whilst eating and drinking. We are aware however that it is impossible to take into account all eventualities for example, where a resident falls ill and needs to be escorted to hospital (leaving staffing numbers unexpectedly depleted at the home) or where staff themselves are unwell and unable to attend work. By way of reassurance, our home managers are at liberty to contact their managers and seek authorisation to arrange for the attendance of ad-hoc bank and agency staff in the event that staffing numbers fall below requirement. Similarly, the on-call management system in place means that out of hours, a manager can attend the home and assist should it be difficult to secure the attendance of ad-hoc bank and agency staff. There is a low threshold for putting in place an additional member of staff in the event of there being any issues that may give rise to concern. 3. Internal review Our operational management team have now had an opportunity to meet with our legal representatives following the Inquest and this meeting highlighted several salient points that were raised, not least the requirement for a review to be undertaken of this matter as you have outlined. In respect of taking this review forward, our operational management team are to now closely consider the findings of your Inquest and other information made available about the tragic incident involving Mr Seaby. The review will assist the operational management team to draw out any salient themes and trends that still exist despite the overarching improvements made and the passage of time. A detailed action plan will be created and any significant learning points will be shared with colleagues at the home and also be shared more widely across Priory services as appropriate. In respect of ensuring that there are proportionate reviews and investigations undertaken in response to serious incidents, I hope that you will be reassured to learn that: 2 The introduction of the Datix incident reporting system in Autumn 2019 has helped management colleagues to better monitor and respond to incidents and near misses. All serious incidents are ‘reported up’. Where necessary a meeting is held the next working day after a serious incident is identified with discussion held in respect of communication with family, staff support and investigation arrangements. Priory are recruiting an additional Investigations Officer to assist in undertaking reviews and investigations. Priory are in the process of adopting the Patient Safety Incident response Framework (PSIRF). This will assist Priory to better examine incident themes and trends and respond proportionately to incidents to achieve the most learning. We anticipate that PSIRF will be fully embedded across Priory Adult Care by Autumn 2023. I trust that the actions outlined above will provide the assurances you seek in respect of this matter. Yours sincerely, ________________ Chief Executive Officer Priory 3
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