Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0382, written 12 Oct 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Oct 2023 |
|---|---|
| Reference | 2023-0382 |
| Deceased | David Hall |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Stockport NHS Foundation Trust |
| 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 FUTURE DEATHS THIS REPORT IS BEING SENT TO: The One Stockport Health and Care Board 1 CORONER I am Alison Mutch, Senior Coroner, for the coroner area of South Manchester 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 16th March 2023 I commenced an investigation into the death of David Hall. The investigation concluded on the 2nd August 2023 and the conclusion was one of Narrative: Died from the complications of poor swallow which developed whilst an inpatient where admission had been due to a shortage of a suitable community placement and discharge was delayed due to a shortage of a suitable social care placement. The medical cause of death was 1a) Aspiration Pneumonia and COVID-19; II) Dementia 4 CIRCUMSTANCES OF THE DEATH David Hall had dementia and was admitted to Stepping Hill Hospital as a consequence of there being no safe and suitable place for him to reside when his usual care arrangement could not continue. He was fit and ready for discharge and was awaiting a placement in a suitable care facility. Whilst in the acute hospital setting, he deteriorated rapidly. His nutritional requirements were not fully met and his swallow deteriorated, which led to further weight loss and ultimately to him developing aspiration pneumonia. Whilst an in-patient he contracted covid 19 which impacted his overall health further. He continued to deteriorate and died at Stepping Hill Hospital on 14th March 2023. 1 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. – The inquest heard evidence that if a suitable emergency social care placement had been available then Mr Hall would not have been admitted to hospital. However, there was no alternative as one could not be found and he was unsafe in the community. His stay in the acute setting led to a rapid deterioration. He had to continue to stay in hospital because a suitable social care placement could not be found for him. The evidence was that had he been in a suitable social care setting his needs would have been met in a more appropriate way. The evidence was that these difficulties in finding a placement were as a result of issues in availability of social care within Stockport. 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 by 7th December 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 namely 1) on behalf of the Family and; 2) Stockport NHS Foundation Trust, who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. 2 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 Alison Mutch HM Senior Coroner 12.10.2023 3
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 Town Hall Stockport SK1 3XE 7 December 2023 [Type here] Ms A Mutch HM Senior Coroner Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG Dear Ms Mutch I refer to the Regulation 28 Report issued following the inquest into the death of Mr David Hall and thank you for contacting Stockport Council. In your report you highlighted areas of concern regarding Mr Hall’s experiences and care provision by adult social care, prior to his admission into Stepping Hill hospital on 28 January 2023. Noted as; Died from the complications of poor swallow which developed whilst an inpatient where admission had been due to a shortage of a suitable community placement and discharge was delayed due to a shortage of a suitable social care placement. Below is a summary of events of Adult Social Care involvement prior to Mr Hall’s admission. Details have been obtained from the records adult social care and NHS hold for Mr Hall. Unfortunately, Stockport adult social care was not made aware of the inquest or identified as an interested party to support the inquest. It is our hope that the information provided in this response is sufficient to highlight the steps taken by adult social care and the NHS providers in Mr Hall’s care. Mr Hall was not previously known to adult social care prior to this intervention. Mr Hall’s daughter, 2023, at 19:15pm. She advised that Mr Hall’s wife, same evening with a suspected fractured Hip and Elbow. be admitted to hospital, and she would be unable to care for her father during this period. , contacted the Adult Social Care Out of Hours Team on the 26 January had been admitted into hospital the may was concerned that confirmed that was Mr Hall’s sole carer and advised that family would be able to support Mr Hall for that evening. At this point a referral was made by the out of hours service to the Heaton Neighbourhood Team to contact Mr Hall, and his family to ensure a short-term plan was in place to support during this difficult time. The following day a referral and information officer from adult social care, contacted further discuss the situation at that time. the previous evening, but also provided further information in respect of the current situation for to again confirmed her father had stayed with her and her father. explained her father was experiencing a deterioration in his physical health, which was resulting in an increase in the care and support he required. This was putting a strain on his wife as his main carer. also described concerns in regard to her father’s memory and cognitive functioning describing an incident where he had tried to leave the property several times and attempted to get out of the property through a window. [Type here] also described her concerns in detail of how and father were managing in their home, in particular concerns around the physical environment. She went on to describe how she felt was not able to continue her caring role, as the physical and emotional needs of her father described how her father’s confusion and agitation was increasing in the were increasing. evenings. She was aware a medication review had been completed by the community mental health expressed concerns that adult social care was not involved and advised team in the past. confirmed that she felt that her father that they required respite care for this period. required support from adult social care. At the time she also described concerns regarding , as a carer. further advised that she works full time and that her husband had taken the day off work to care for her father. She advised that they would not be able to continue this and required residential respite care. also advised that, she had contacted the crisis response team. We have no record of the outcome of this contact on Mr Hall’s record. The same day was contacted by the duty social worker, who liaised with the crisis response team, working with individuals through a multi-disciplinary approach to support people in their own home. From discussions with this team, it was felt that they would not be able to support Mr Hall at that time due to his level of need. To ensure all necessary information was considered to inform any interventions discussions were also held with the community mental health team. They advised they had previously supported Mr Hall, but he was not currently receiving support from them. The duty social worker then confirmed with that respite care would be arranged as soon as a provider that was able to meet Mr Hall’s needs was identified. She was asked to discuss this option with her father to determine how Mr Hall felt about going into respite care. confirmed that Mr Hall was in support of respite care. Thirteen residential homes were contacted, and there was no emergency respite provision available, the same day. One of the providers was able to support from the following Monday. Enquiries were made to secure a night service for Mr Hall from the in-house provider. Following this stated that she was unable to provide her father with support over the weekend and she had contacted his GP. Due to this further consideration was given to support that would be immediately available, but no further provision was found on 27th January 2023. was contacted with an update, Following the call to the GP Mr Hall was admitted to Stepping Hill hospital, Mr Hall was admitted on 28th January 2023 due to a urine tract infection, acute confusion, agitation, and pseudo gout. The Foundation Trust records show Mr Hall was identified to move to Hilltop Home, a nursing home for people with Dementia. This was his discharge pathway from hospital. Unfortunately, Mr Hall was confirmed as Covid positive, on 28th February 2024 which delayed his discharge. Further arrangements were then made to support Mr Hall on 13th March 2023, but unfortunately, he was too poorly to leave hospital as he was receiving treatment. It is important to note, the UTI diagnosed by Mr Halls’ GP on 28 January was one of the reasons he was admitted into hospital. The impact of this was such that the GP supported a hospital admission. [T[T[T[T[T[T[T[T[T[T[T[T[T[T[T[T[T[T[T[TT[TTT[[[[T[[T[[T[T[[T[T[T[T[T[T[T[T[T[T[T[T[T[T[T[TTT[T[TT[T[T[TT[T[T[TT[TTT[T[T[T[TTT[T[T[[T[T[T[T[TT[[T[TTT[TTT[[T[[[T[[[[[[ ypypypypypypypypypypypypypyypypypypypypyyyppypyyypypypypypypypypypyppyppypyypyppyppypypypypypypyyppypypypyyypypyyyyppypypyyppypypyyppyyyypyypyppyypypppppypyyppppyypyyyyyyyypeeeeee hehehehehehehehhhhehehehhehhehehhhhhhhhhhhheheehhheeheehhehhhheheeeeeeeeeeereeeeee] [Type here] Commissioning concerns relating to the Regulation 28 Report In relation to the regulation 28, I have noted below some of the work currently ongoing within adult social care to ensure that we have a safe, efficient, and effective provision of care for our residents. Adult social care discharges its duty under the Care Act with the availability of care and support services, for delivering care and support and avoiding admissions into hospital. This also includes an emergency response when carers are unable to continue in there caring role(s). We will utilise residential and nursing beds within the community, some of whom adult social care block book for availability. We acknowledge the challenges in the social care market and are continually working to address these through more flexible, sustainable and outcome focussed services. It is particularly challenging working within the independent sector and the Council acknowledge the services they provide on our behalf and work in partnership to address any gaps in our market. This is a particular issue where emergency step up support is concerned where there is a need to respond at short notice to avoid an individual being admitted into hospital. We know capacity in the market fluctuates and seasonal pressures can exacerbate the ability to place individuals at short notice. However, we have and are continuing to take steps to improve the capacity in the care market and to ensure providers can support individuals at short notice. For instance, we have dedicated step down capacity that could be flexed to accommodate individuals and have recently utilised short-term funding to provide same day pick up of home care support. The relatively high levels of occupancy in the nursing care market in Stockport provide some sufficiency challenges where there are higher levels of demand for this type of placement. The number of vacancies in care homes in Stockport is currently steady with the longer-term trend being an increase in occupancy. The assessment is that the numbers of beds available in Stockport are generally sufficient to meet the demands placed on the sector by the Council and health partners although this is subject to fluctuations in demand. Yours sincerely Chief Executive
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