Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0302, written 11 Aug 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Aug 2023 |
|---|---|
| Reference | 2023-0302 |
| Deceased | Doris Urch |
| Coroner | Harry Lambert |
| Coroner area | Inner North London |
| 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: Prevention of Future Deaths report
Doris Irene URCH (died 28.02.23)
THIS REPORT IS BEING SENT TO:
1.
Managing Director
Globe Court Care Home
50 Globe Road
London E1 4DS
1
CORONER
I am: Harry Lambert
Assistant Coroner
Inner North London
Poplar Coroner’s Court
127 Poplar High Street
London E14 0AE
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 3 March 2023 the Senior Coroner, Mary Hassell, commenced an
investigation into the death of Doris Urch aged 90 years. The
investigation concluded at the end of the inquest on 27 July 2023.
The Inquest found that on 6th February 2023 Ms Urch fell, after her carer
omitted to offer her support whilst ambulating. The risk of falls had been
inadequately addressed in the Risk Assessment documentation and
procedure. Although the Deceased appeared not to be seriously injured
in the wake of the accident it was later confirmed on CT scan that she had
suffered a brain injury, from which she later died
I returned a narrative conclusion in the following terms:
On 28th February 2023 Ms Urch died from an intracranial haemorrhage
1
sustained in a fall on 6th February 2023, after her carer omitted to offer support
whilst ambulating.
The medical cause of death was
1a Acute left frontal intracranial haemorrhage
2 Alzheimer’s Dementia
4
CIRCUMSTANCES OF THE DEATH
Doris Irene Urch, aged 90, suffered from Alzheimer's dementia, and age
related macular degeneration, and was known to have a high risk of falls.
, from whom I heard evidence, that the most
I was told by
risky transition was from standing to sitting and that during this transfer
the Deceased, due to her visual impairment, would often miss the seat
and fall. It was “part of her” which I took to mean an inherent and
constant risk.
that “we all knew you had to watch Doris when she sits down”.
, the care home manager, candidly accepted
On 6th Mrs Urch was in the lounge of Globe House when she became
distressed, lost her balance and fell.
It is clear that Ms Urch was not being supervised or assisted by the only
, who was “sitting…with the other residents”.
carer present,
acknowledged that this was a mistake.
She was taken to Hospital where a CT scan evinced a large acute left
frontal intracranial haemorrhage with extensive longstanding cerebral
atrophy. It was decided that surgical intervention was not in her best
interests and the focus shifted to palliative care.
She passed away on 28th February 2023 at around 03:30 hours.
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.
2
(1) The Question and Answer tickbox form for Risk Assessment
seemed to me to leave much to be desired. It was excessively
binary and meant that those who filled it in did not need to
“engage” with the particular patient.
(2) The Risk Assessment did not make no recommendations or
suggestions as to what to do about the risks identified.
(3) Staff seemed unfamiliar with the risk assessment/care plan, which
I consider more of a systemic problem. It is unclear if/when care
plans were reviewed by staff.
(4) The care plan/risk assessment was not updated in light of a fall in
November/December 2022. I was concerned that potentially
significant developments might not be being taken into account in
keeping the care plan under review.
(5) The system does not preserve old care plans in their
contemporaneous format which is a serious shortcoming which
has the potential to hinder future investigations. I encourage that
system to be reviewed.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that 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 by 6th October 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
3
I have sent a copy of my report to the following.
, aunt of Irene Urch
•
• Care Quality Commission for England
• HHJ Thomas Teague QC, the Chief Coroner of England & Wales
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
interest. You may make
he believes may
representations to me, the coroner, at the time of your response, about
the release or the publication of your response.
it useful or of
find
9
DATE SIGNED BY ASSISTANT CORONER
11.08.2023
4
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.
Action Plan to Prevent Future Deaths Directors: Manager Name: (Quality Assurance) Date: Areas of Concern: 1. Question & Answer tick box for risk assessments on the PCS system we use within our care homes 2. Risk assessments not making recommendations when risks have been identified 3. Staff being unfamiliar with care plans and risk assessment 4. Care plans and risk assessments not being updated 5. PCS system not preserving old care plans/risk assessments and reviewing the system in place. Discussions: 1. We have been using the PCS system (Person Centered Software) in all of care homes. Any risk assessments are person centered around the resident to identify risks. 2. We have checked with PCS and although risk assessments are archived residents care plans are not. This is due to care plans being reviewed on a monthly basis if not sooner depending on if circumstances change with that resident. 3. All staff use a handheld device where they have access to residents care plans and risk assessments. This will be part of our action plan to ensure that during inductions staff are shown how to access information on residents and use the devices effectively. 4. All care plans and risk assessments are reviewed and updated monthly. 5. As care plans are reviewed and updated regularly to reflect residents support we fill that it works effectively as the information on care plans are up to date. Action Plan: Completion Date: The prevention of future deaths in care facilities requires adherence to strict safety protocols and procedures. Here are some key measures we have taken to reduce the risk of future deaths: Training and supervisions: All staff are up to date with training except new employee’s who complete mandatory training before starting in their post and then they have 12 weeks to complete the rest of their training schedule. 1. Staff training and supervision: Ensure that all staff members undergo rigorous training and are aware of the correct procedures for providing care and Care plans and risk assessments are reviewed monthly but sooner if changes need to be made to support residents. This will continue to be ongoing in the future. Staff are aware that any safeguarding concerns need to be reported to the manager straight away so that correct procedures are followed. This is ongoing. All staff have been trained on how to use the PCS device and where to find all relevant information on residents. This also includes agency staff and new employees. PCS training has been added to our induction programme for new staff. All staff have access to a list of residents who are potentially at high risk of harm. The list is updated as and when and will continue to be ongoing. Manger, Deputy Manager, Team leaders check documentation regularly and inform staff members if they need more detailed documentation. This is ongoing. responding to emergencies. Regularly assess and update staff knowledge and skills. Provide adequate staffing levels to ensure proper supervision and monitoring of residents. 2. Risk assessment: Conduct regular assessments of residents to identify any potential risks to their health and safety. This includes assessing their physical and mental health needs, as well as their mobility and potential risks such as falls or wandering. 3. Safeguarding procedures: Implement robust safeguarding procedures to protect residents from abuse, neglect, or exploitation. Encourage staff to report any concerns or suspected incidents promptly. Conduct thorough investigations and take appropriate action when incidents are reported. 4. We have implemented training on the PCS handheld devices during induction for staff. This will give all new members of the team the knowledge and skills on how to use the device correctly and effectively. 5. We have implemented a list of residents who are high risk of falls to ensure that not only our regular staff and new staff but also agency staff know who are potentially at risk of harm 6.Documentation will be checked on a regular basis to ensure staff are documenting correctly and effectively.
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