Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0421, written 31 Jan 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 Jan 2023 |
|---|---|
| Reference | 2023-0421 |
| Deceased | Evelyn Burcham |
| Coroner | Samantha Marsh |
| Coroner area | Somerset |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 4 |
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:
1. Health and Safety Executive
Redgrave Court
Merton Road
Bootle
Merseyside
L20 7HS
2.
, Department of Health and Social Care
House of Commons
London
SW1A 0AA
3. Care Quality Commission
2 Redman Place
London
E20 1JQ
1 CORONER
I am Mrs Samantha Marsh, Senior Coroner, for the coroner area of Somerset
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 the 28th of December 2022 I commenced an investigation into the death of
Evelyn Ann Burcham, aged 96. The investigation concluded at the end of the
inquest on the 27th September 2023. The conclusion of the inquest was
‘Accidental Death’ with the medical cause of Mrs Burcham’s death being given
as:
Ia) Head Injury
4 CIRCUMSTANCES OF THE DEATH
Mrs Burcham had resided at Frethey house Nursing Home (“the Home”) since
May 2017. She had suffered a stroke in 2016 and her condition had
1
progressively worsened due to dementia. Mrs Burcham was incapable of doing
anything for herself and she relied on the staff at the Nursing Home to anticipate
and meet her every need and provide her with full care, including; personal care,
hoisting, transfer, nutrition etc. She also lacked capacity and could only
communicate through incoherent mumbling and facial expressions, which the
staff who knew her well at the home had learned to interpret.
The Home is a residential and nursing home which, whilst accepting patients
with dementia, is not a dementia specialist service.
On the 14th of December 2022 the Home had organised a carol concert in the
communal lounge as part of their Christmas celebrations. It was attended by
residents and their families, staff and church volunteers.
Mrs Burcham was brought to the lounge and hoisted into a standard riser-
recliner chair. As she lacked any ability to support her own posture she was
wedged in with pillows and the chair legs elevated by staff (via the remote
control) to prevent her from slipping out. Carers then went to assist other
residents to access the lounge ahead of the concert starting.
The riser recliner chair that Mrs Burcham was in appeared to be a fairly standard
design; an electric chair plugged in at the mains to enable the mechanism via a
remote control, which is attached to the chair via a cord, with a side pocket for
storage of the remote control whilst it is not in use.
Whilst Mrs Burcham was in the riser-recliner chair unattended, another resident
of the Home has accessed the remote control for the chair. This other resident
had dementia which manifested itself in a compulsion to randomly fiddle. The
other resident fiddled with the remote control buttons as they were accessible,
unlocked and unsupervised and, without any intention or malice (or indeed any
appreciation whatsoever of what she had done, because of her own cognitive
impairment) managed to elevate the chair to its full rise position and tip Mrs
Burcham onto the floor. Mrs Burcham had no power of speech to call for help,
nor was she able to support her own weight or break her fall. She landed on
her head and sustained a severe bleed on the brain, sadly dying of her injuries
ten days later.
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 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. –
I am concerned that these chairs are common place in care home settings
where residents suffer from cognitive impairment. The risks of another resident
with dementia accessing the controls of the riser-recliner chair(s) was not
foreseen by the Home and so was not factored into any operative risk
assessment at the time; hence no measures were in place to minimise the risk.
There remains a real and immediate risk that those with a cognitive impairment
that manifests itself in a compulsion to fiddle and/or press buttons, can create a
risk of death to other residents in the same care facility or setting. If this
particular care home group did not foresee the risk then it is likely that others
have not foreseen it either.
2
I was told at the Home had made enquiries with manufacturers of these
standard riser-recliner chairs about the ability to ‘lock’ the remote control and/or
find a safe was of storing it so that it is not accessible to anyone who does not
have the authority, training or appropriate cognitive function to be able to use it
safely. It would appear that a chair with a ‘safe’ remote cannot be purchased by
the Home and there do not appear to be any regulatory or manufacturing
standards (over and above manufacturing standards for consumers) that require
these types of chairs to have this, or some alternative, safety feature that limits
the use of the controls. I was told that the only way to render the remote ‘safe’
was to turn the power off at the mains, which in itself could create health and
safety issues if the chair needed to be operated quickly.
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 the 26th December 2023. I, the coroner, may extend the
period and am conscious that the deadline falls on Boxing Day. I would
appreciate an early request for an extension if a response cannot be provided
before Christmas closures.
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:
(i) the Chief Coroner
(ii) Mrs Burcham’s family
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 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.
9
31st October 2023
3
4 responses 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.
Samantha Marsh Senior Coroner for Somerset Coroner's Office Old Municipal Building Corporation Street Taunton TA1 4AQ 17th November 2023 Dear Mrs Marsh I write further to the Inquest into the death of Mrs Evelyn Ann Burcham, 27th September 2023 and your request that within 56 days Aria Care provide a response to the following matters: a) the results of discussions with manufacturers about lockable controls; and b) Following the Quarterly meeting, any other ideas from Aria about how to reduce this risk. Following receipt of the request, Aria Care reached out to Shackleton’s, our furniture supply partner seeking advice and guidance on riser/recliner chairs and the potential for purchase and supply of handsets that could be locked in a secure position and avoid unauthorised access and repositioning. Shackleton’s advised that due to the large number of riser/recliner manufacturers that a single universal handset, with a lockable feature, was not possible to supply, however, they are able to provide a lockable handset for the chairs they supply. We have trialled this control with other chairs and have had mixed results, with 15% of the chairs tested not suited to the Shackleton’s supplied handset. We have now directed that all future request for the supply of riser/recliner chairs will be processed via Shackleton’s and that all chairs supplied to Aria Care will be fitted with lockable handsets. From the 01st December 2023, residents being newly admitted to the home will be made aware of the Aria Care’s requirement for all privately purchased riser/recliner chairs to come fitted with lockable handsets. Where residents are currently living in our care homes and have purchased privately their riser/recliner chair, and this device is not fitted with a lockable handset, we will work with that resident and/or their family to seek a solution and ensure the riser/recliner is replaced by a chair that has a lockable handset. We anticipate this may take the first quarter of 2024 to fully resolve, where the equipment supplied is privately owned and already in use. In the meantime, our property services department are working with NH Maintenance (NHM), to explore other options, including the development of a cover that could potentially be used universally, to restrict access to the handset controls, this device would be lockable. Whilst NHM state they would be able to deliver such a device, they have indicated that development and trial takes time and that they may not be able to provide an immediate short-term solution but could within 2-3 months provide a universal lockable cover. Whilst waiting on the development by NHM, we will look to use the controls provided by Shackelton’s to reduce unauthorised access to riser/recliner chair controls, where they are compatible. For chairs where we cannot control access via the introduction of the covers, we have introduced generic and individualised risk assessments which include the requirement to: maintained a safe distance between the riser/recliner and other seating, reducing access to handsets. where a resident lacks the physical or cognitive ability to independently control the riser/recliner chair, that once positioned comfortably colleagues will isolate the electrical flow to the chair preventing unauthorised access and repositioning. Aria Care are committed to delivering a long-term solution to this problem, but have encountered challenges, due to the variety of chairs available across the national marketplace. We are also aware that any decision taken, regarding existing riser/recliner chairs needs to consider those chairs owned or purchased privately and that we will need to liaise with residents and their families to transition to the supply of lockable handsets only devices within our homes. We have also reached out to the Care Quality Commission, via our corporate link, seeking the Commissions view in regard to our risk reduction approach and specifically any concerns where our plans or approach might impact residents’ rights in relation to restrictive practices and how we ensure we deliver the correct balance between safety and restriction. At our Quarterly Quality Assurance Meeting the adverse event involving Mrs Burcham was revisited, and the following outcomes agreed: 1) 2) 3) Introduction of generic risk assessment for colleagues to support the safe use of riser/recliner chairs. This document provides a general guide to colleagues on measures to be taken to safely use and maintain a riser/recliner chair, without taking into consideration the specific and unique needs of the person using the equipment. Introduction of resident specific risk assessment for suitability to use a riser/recliner chair. This document builds on the generic risk assessment and provides details for colleagues of how to support individual residents use the equipment safely based on their physical and cognitive abilities and support needs. Introduction of an asset register for riser/recliner chair use/deployment, be that supplied by Aria Care or specifically purchased by the resident or their family. 4) Completion of an organisational wide survey to understand the extent and supply of riser/recliner within Aria Care. 5) Agreement that via a phased approach Aria Care will reduce the use of riser/recliner chairs across the organisation and where an assessed need exists, riser/recliner furniture will be purchased solely from Shackleton’s, as our furniture partner, with lockable handsets. We trust that the actions we have taken and those we propose to take provide assurance of our commitment to resident safety and wellbeing. Every effort is being made to reduce the risks associated to the supply and correct use of riser/recliner chairs within our homes and we will continue to seek additional control measures to further mitigate risks to people living in our homes and to learn from adverse events, such as this and the sad loss of Mrs Burcham. Yours sincerely. , Director of Quality & Governance, Aria Care Group.
From Minister Whately Minister of State for Social Care 39 Victoria Street London SW1H 0EU 020 7210 4850 26/04/2024 Mrs Samantha Marsh, Coroner’s Office, Old Municipal Building, Corporation Street, TAUNTON, Somerset, TA1 4AQ Dear Ms Samantha Marsh, Thank you for your Regulation 28 report to prevent future deaths dated 31/10/2023 about the death of Evelyn Ann Burcham. I am replying as Minister with responsibility for adult social care. Firstly, I would like to say how saddened I was to read of the circumstances of Ms Burcham’s death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for the delay in responding to this matter. Your report raises concerns over electric riser-recline chairs which are commonplace in care home settings, including where residents suffer from cognitive impairment, and the risks of another resident with dementia accessing the controls of the chair(s). The report also raises concerns about the ability, or lack of ability, to ‘lock’ the remote control and/or find a safe way of storing it so that it is not accessible to anyone who does not have the authority, training or appropriate cognitive function to be able to use it safely. In preparing this response, Departmental officials have made enquiries with NHS England and the Care Quality Commission (CQC). The Department is content that the CQC have discussed the case internally on 06/01/23, including actions taken to date and proposed future actions. It was agreed that further information was required from the provider about the incident. CQC received the information requested and held further internal discussion on 13/02/23. CQC assessed that there was sufficient evidence to refer the incident to the Criminal Enforcement Support Hub (CESH) prior to a Criminal case assessment and progression panel (CCAPP) referral. This referral was made on 15/02/23. This case was accepted as a potential specific incident and assigned an 1 investigator from CQC’s national enforcement team; investigations are now complete, and it has been adjudged that CQC has no basis to take further action as there is insufficient evidence linking this directly to a registered person. The family were made aware of the outcome of CQC’s decision and CQC will continue to monitor the provider. We are also pleased to read that Aria Care along with support from the CQC have moved to use lockable remotes on riser-recliner chairs and agree other actions to prevent a tragic event such as this happening again, I hope this response is helpful. Thank you for bringing these concerns to my attention. Helen Whately MP
From Minister Whately Minister of State for Social Care 39 Victoria Street London SW1H 0EU 020 7210 4850 26/04/2024 Mrs Samantha Marsh, Coroner’s Office, Old Municipal Building, Corporation Street, TAUNTON, Somerset, TA1 4AQ Dear Ms Samantha Marsh, Thank you for your Regulation 28 report to prevent future deaths dated 31/10/2023 about the death of Evelyn Ann Burcham. I am replying as Minister with responsibility for adult social care. Firstly, I would like to say how saddened I was to read of the circumstances of Ms Burcham’s death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for the delay in responding to this matter. Your report raises concerns over electric riser-recline chairs which are commonplace in care home settings, including where residents suffer from cognitive impairment, and the risks of another resident with dementia accessing the controls of the chair(s). The report also raises concerns about the ability, or lack of ability, to ‘lock’ the remote control and/or find a safe way of storing it so that it is not accessible to anyone who does not have the authority, training or appropriate cognitive function to be able to use it safely. In preparing this response, Departmental officials have made enquiries with NHS England and the Care Quality Commission (CQC). The Department is content that the CQC have discussed the case internally on 06/01/23, including actions taken to date and proposed future actions. It was agreed that further information was required from the provider about the incident. CQC received the information requested and held further internal discussion on 13/02/23. CQC assessed that there was sufficient evidence to refer the incident to the Criminal Enforcement Support Hub (CESH) prior to a Criminal case assessment and progression panel (CCAPP) referral. This referral was made on 15/02/23. This case was accepted as a potential specific incident and assigned an 1 investigator from CQC’s national enforcement team; investigations are now complete, and it has been adjudged that CQC has no basis to take further action as there is insufficient evidence linking this directly to a registered person. The family were made aware of the outcome of CQC’s decision and CQC will continue to monitor the provider. We are also pleased to read that Aria Care along with support from the CQC have moved to use lockable remotes on riser-recliner chairs and agree other actions to prevent a tragic event such as this happening again, I hope this response is helpful. Thank you for bringing these concerns to my attention. Helen Whately MP
Health and Safety Executive Engagement & Policy Division Head of Local Authority & Safety Unit 2, Victoria Place Carlisle Cumbria CA1 1ER Mrs Samantha Marsh (Senior Coroner) Coroner’s Office Old Municipal Building Corporation Street TAUNTON Somerset TA1 4AQ Date: 19 December 2023 Dear Madam REGULATION 28 PREVENTION OF FUTURE DEATH – RECLINER CHAIR Thank you for your report sent to Burcham of Frethey House Nursing Home. Mrs Burcham suffered a head injury when she fell from a standard riser-recliner chair after it was operated by another resident, while unattended by nursing home staff. I am responding as the Head of Local Authority and Safety Unit at the Health and Safety Executive (HSE) which leads on workplace product safety. , HSE Chief Executive, in relation to the death of Mrs Your report highlights, as matters of concern, that these chairs are commonplace in care home settings where residents suffer from cognitive impairment that manifests itself in a compulsion to fiddle and/or press buttons, and that the risk of other residents with dementia accessing the controls was unforeseen. This did not feature in any risk assessment undertaken by the home and therefore measures were not put in place to address this risk. There are a number of regulatory regimes that may be applicable to the circumstances, and I provide some detail on these below. In England, the Care Quality Commission (CQC) is the lead inspection and enforcement body for safety and quality of treatment and care matters involving patients and service users in receipt of a health or adult social care service from a provider registered with CQC. The Memorandum of Understanding between CQC and HSE explains the respective roles and responsibilities of each organisation with regard to health and safety incidents in the health and adult social care sectors. This means that, in general, where care homes are registered with CQC, then CQC will be responsible for regulating the safety, quality of treatment and care matters involving service users and patients. HSE or the Local Authority will be responsible for the health and safety matters involving workers, visitors and contractors. HSE is the enforcing authority for care homes with nursing where the main activity is the provision of nursing/medical care. Local Authorities are the enforcing authority for care homes where the main activity is the provision of residential accommodation. The Health and Safety (Enforcing Authority) Regulations 1998 set out the enforcement allocation of workplaces between Local Authorities and HSE. As this case involves a service user/patient it would not be a matter for HSE enforcement and would instead fall within the remit of CQC. With regard to product safety matters, the chair involved in this tragic incident would appear to meet the definition of a ‘machine’, and therefore the relevant supply legislation would be the Supply of Machinery (Safety) Regulations 2008, which implemented the EU Machinery Directive 2006/42/EC in GB. HSE is responsible for the enforcement in respect of unsafe workplace machinery placed on the market in GB. However, for consumer products, it is Trading Standards. Standard riser-recliner chairs are widely used domestically. If anyone can purchase the chair for use at home then it would normally be considered as a consumer product and be regulated by local authority Trading Standards. After receiving your report, HSE contacted the other regulatory bodies who may have an interest or potential regulatory role in respect of this incident. We have written to CQC (who are already in receipt of your report) on the patient safety aspects. HSE has also notified the Office for Product Safety and Standards (OPSS) who are the national regulator for consumer products and who work with the local authority Trading Standards services that undertake most enforcement activity. I would seek your permission to share your report with OPSS who will be able to consider the consumer safety aspects and liaise with Trading Standards as appropriate. Alternatively, you may contact OPSS directly at the following address: Graham Russell, Chief Executive Officer, The Office for Product Safety and Standards, Dept. for Business and Trade, 4th Floor Cannon House, 18 The Priory, Queensway, Birmingham, B4 6BS. I hope that the above information is of assistance and addresses the matters raised. Yours faithfully Head of Local Authority and Safety Unit 2
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