Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0430, written 7 Nov 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Nov 2023 |
|---|---|
| Reference | 2023-0430 |
| Deceased | Irene White |
| Coroner | Samantha Marsh |
| Coroner area | Somerset |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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. Frome Nursing Home
Styles Hill
Frome
Somerset BA11 5JR
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 20th of October 2022 I commenced an investigation into the death of
Irene Joy White, aged 77. The investigation concluded at the end of the inquest
on the 1st of November 2023. The conclusion of the inquest was ‘The deceased
died of a pulmonary embolous which developed on a background of early
discontinuation of thromboprophylaxis and immobility following a fall and fixation
operation” with the medical cause of
Ia) Saddle Pulmonary Embolous
Ib) Deep Vein Thrombosis
Ic) Immobility
II) Fractured neck of femur (operated on in June 2022)
death being given as:
4 CIRCUMSTANCES OF THE DEATH
Mrs White had a diagnosis of dementia and had lived in her previous care home
since November 2019. Unfortunately her cognitive impairment meant that her
behaviours put others at serious risk of harm and/or death (she is recorded as
having tried to suffocate another resident with a pillow) and so her previous
home had identified that they could no longer meet her needs and sought to find
another appropriate placement for her due to being unable to manage her
unpredictable aggression and ‘assaults’ on other vulnerable residents.
On the 29th May 2022 she was found on the floor of her previous care home
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having suffered an unwitnessed fall. She was conveyed to hospital where it was
revealed she had sustained a fractured hip. She underwent a surgical fixation
operation on the same day.
Post operatively she was given two forms of thromboprophylaxis:
(i) Chemically, with inhixia injections; and
(ii) Physically with TED compression stockings.
Mrs White was discharged to a new Nursing Home, Frome Nursing Home, on
the 17th June 2022 and was discharged with no thromboprophylaxis (either
chemical or physical) and no advice. Mrs White was due to have a further nine
days of thromboprophylaxis to complete the routine 28-day course (having only
had 19 days at the point of discharge).
Frome Nursing Home is an Older Persons Mental Health care home, so can
accept residents with complex dementia needs, such as Mrs White. There is at
least one qualified and registered Nurse on duty 24/7.
Mrs White had no risk factors that pre-disposed her to developing a DVT; her
risk factor was immobility following her fall.
Irene was not provided with any thromboprophylaxis measures and was not
mobilised over and above being repositioned every four-hours for skin integrity
and pressure-sore prevention.
Mrs White died of a pulmonary embolism, which developed following her fall and
immobility, on the 20th of October 2022.
.
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 following the evidence presented to the Inquest that:
(i) Frome Nursing Home employs clinically trained staff who would have
been well aware (or should have been well aware) of the risk of
developing DVT in an immobile patient and yet:
(a) Did not make any enquiries with the discharging hospital as to her
care needs and lack of thromboprophylaxis. Despite appropriate
medical/clinical knowledge the Home did not question this and/or take
any active steps whatsoever to ascertain Mrs White’s needs or
treatment plan;
(b) Did not take any steps to acquire any TED stockings, or similar, to
minimise the risk of a DVT;
(c) Did not take any steps to mobile Mrs White, over and above
repositioning her in bed every four hours, to minimise the risk of a
DVT
(ii) Frome Nursing Home did not have a DVT Policy in place at the time of
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Mrs White’s death, and no such active policy was in place at the time of
the Inquest and so I am concerned that there has been no active learning
and/or meaningful reflection since Mrs White’s death; meaning that
practices have not changed and vulnerable residents remain at risk.
I am concerned that the Home did not take appropriate and reasonable steps to
identify her risk and then take such steps to minimise it. The overwhelming
thrust of the evidence presented indicated a poor attitude to a joined-up and
cohesive response from the management and clinical teams and this resulted in
a lack of clinical leadership, judgment and action being taken.
Mrs White lacked capacity due to her cognitive impairment and so was unable to
appreciate the risks that immobility posed to her. She was entirely reliant
(because of age, cognitive impairment and general infirmity) on the Home to
anticipate her risks and needs in this regard.
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 2nd January 2024. 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 White’s family
(iii) Care Quality Commission
2 Redman Place
London
E20 1JQ
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.
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You may make representations to me, the coroner, at the time of your response,
about the release or the publication of your response.
9
7th November 2023
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