Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0541, written 4 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 | 4 Oct 2023 |
|---|---|
| Reference | 2023-0541 |
| Deceased | Janet Spencer |
| Coroner | Michael Wall |
| Coroner area | Nottingham City and Nottinghamshire |
| 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: 1 Corporate Director for Adult Social Care and Public Health, Nottinghamshire County Council, County Hall 1 CORONER I am Mr Michael Wall, HM Assistant Coroner, for the coroner area of Nottingham City and Nottinghamshire 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 Coroner’s (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 10 October 2022 I commenced an investigation into the death of Janet Irene SPENCER aged 76. The investigation concluded at the end of the inquest on 21 September 2023. The conclusion of the inquest was: Accident. 4 CIRCUMSTANCES OF THE DEATH (relevant to this report) Janet had an unwitnessed fall while in the lounge area of her assisted living accommodation on 30 August 2022. She pressed her call buzzer and notified staff. A support worker attended promptly. Janet was conscious. She reported having hit her head. An ambulance was called and paramedics attended. Janet was transported to Kings Mill Hospital where it was identified that she had suffered an acute subdural haematoma. Surgical intervention was deemed not appropriate. Janet was placed on end-of-life care. Despite a period of a few days when she appeared to improve, she did not recover and remained in hospital until her death some 13 days later. Janet died as a result of a traumatic acute subdural haematoma sustained in the fall, with underlying ischaemic heart disease contributing to but not directly causing her death. 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. Janet had a recent but significant history of frequent falls, some causing serious injury. A care assessment commenced on 6th May 2022 and updated on 10th May 2022, identified that she had reablement potential but further assessment of her needs was required. Regulation 28 – After Inquest Document Template Updated 30/07/2021 On 16th May 2022 she was admitted to the assessment unit at Gladstone House, an assisted living facility. On 25th May she suffered a further fall, fracturing her right neck of femur. She was admitted to Kings Mill Hospital. On 22nd June 2022 a discharge to assess referral form was completed. It included limited detail of her care needs and a single-sentence reference to the fall on 25th May. On 14th July 2022, Janet was discharged to Nightingale Care and Nursing Home. On 18th July 2022 she had an unwitnessed fall there. Fortunately, she sustained no significant injuries on that occasion. On 26th August 2022 Janet transferred to Gladstone House. On 30th August 2022 she suffered the fall which ultimately led to her death. The evidence heard from staff at both care facilities was consistent in two significant respects: i) they were provided with very little information in advance of the transfer; and ii) the transfer was arranged hastily, which resulted in both facilities having limited opportunity to liaise with each other, or to prepare for and ensure it proceeded smoothly. I remain unclear as to the precise reasons for Janet’s transfer from Nightingale to Gladstone House on 26th August 2022 and why it appears to have been arranged with such haste. No updated care assessment was made prior to transfer. An error occurred between the care facilities which resulted in Janet not receiving two of her prescribed medications following her transfer to Gladstone House. While this did not cause or contribute to Janet’s death, the importance of care facility residents receiving the correct medication needs no emphasis. This error occurred in part because of flaws in the systems of the two care facilities, which I am satisfied have since been addressed. However, the evidence suggests that it was also due, in part, to the haste with which the transfer was arranged and the lack of coordination of it by the social care team. I heard evidence that the systems in respect of discharges and transfers to Gladstone House have since been improved. I was told that both that provider and the social care team based on site, do now have better systems in place and work closely together to ensure that sufficient information is provided in respect of any referral. However, I was also told that Gladstone House have no power to refuse any referral even if they consider the information provided by social care to be insufficient. Furthermore, the Adult and Social Care Team, Team Manager who gave evidence on behalf of NCC, was (through no fault of her own) unable to assist me with details of any changes that may have occurred more widely within the discharge to assess team since August 2022. I cannot therefore be satisfied that these issues have been adequately addressed. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) The systems in place in respect of discharge to assess patients do not appear to 1. ensure patients are discharged or transferred between care facilities with an adequate and up to date risk assessment and care plan in place. The systems in place in respect of discharge to assess patients do not appear to 2. ensure a smooth transition between care facilities, especially when transfers are arranged at pace. In particular, they do not appear to ensure that all involved have the information they require to contribute effectively to the transfer process. Regulation 28 – After Inquest Document Template Updated 30/07/2021 Although they did not cause or contribute to Janet Spencer’s death, I am concerned that the issues identified above give rise to a risk of deaths occurring if they go unaddressed. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) 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 29 November 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: 1. Janet’s daughters 2. Fosse Healthcare 3. Jasmine Healthcare 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: 4 October 2023 Michael Wall HM Assistant Coroner For Nottingham City and Nottinghamshire 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.
##MAILMERGE - Do not delete this text or change the colour from white
This matter is being dealt with by:
W nottinghamshire.gov.uk
Private and Confidential
To be opened by addressee only
Michael Wall
HM Assistant Coroner
For Nottingham City and
Nottinghamshire
Dear Michael
28 November 2023
RE:
- Janet Irene SPENCER - Regulation 28 Prevention of Future Deaths
Please see below our response to the matters of concerns as set out in section 5 of the report:
"The MATTERS OF CONCERN are as follows:
(brief summary of matters of concern)
The systems in place in respect of discharge to assess patients do not appear to ensure
patients are discharged or transferred between care facilities with an adequate and up to
date risk assessment and care plan in place.
1. Nottinghamshire County Council has a joint strategy and policy with partners in the Nottingham
and Nottinghamshire Integrated Care System (ICS) in line with national NHS England
Discharge to Assess (D2A) Policy and Guidance.
2. Under this model there are four routes out of hospital for people as follows:
• P0 – No additional support required on discharge at home from Adult Social Care but could
include District Nursing input
• P1- Reablement or rehabilitation at home- in Nottinghamshire this is provided by the Local
Authority (LA) and NHS Community Health Provider
• P2- Residential rehabilitation or further assessment- this is provided by the NHS.
• P3- Complex discharge planning, often including assessment for Funded Nursing Care or
NHS Continuing Healthcare – this is also an NHS provision on discharge from hospital.
3. The Nottingham and Nottinghamshire ICS D2A policy and procedure has been agreed between
NHS and Local Authority partners and is as follows:
A ‘Discharge to Assess’ referral form is completed by the NHS ward staff caring for the person,
this details their care and support needs, risk assessment and where appropriate consideration
of Mental Capacity and Best Interests relating to further
care/rehabilitation/reablement required for hospital discharge.
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The Council is committed to protecting your privacy and ensuring all personal information is kept confidential and safe. For more details
see our general and service specific privacy notices at: https://www.nottinghamshire.gov.uk/global-content/privacy
Nottinghamshire County Council, County Hall, West Bridgford, Nottingham NG2 7QP
4. The Discharge to Assess form is sent to the ‘Transfer of Care Hub’ - which is a multi-disciplinary
Team sited within the hospital. Each referral to the Hub is discussed by the team which includes
NHS and LA Social Care professionals, also linking with District Council and Community &
Voluntary Sector staff as required. The Multi- Disciplinary Team make a joint decision regarding
which pathway the person requires to ensure a safe discharge from hospital with appropriate
care, support and reablement to promote their wellbeing and independence.
5. The Pathway decision and referral forms are shared with the care provider, for example for
people leaving hospital to return home on Pathway 1 (social care supported discharge) this
information is shared with the LA Services, and for those being supported via Pathway 1 by
Community Health Provision- information is shared accordingly. This information pack also
includes a discharge summary and medication list / arrangements.
6. In Mrs Spencer’s case she was assessed to require a Pathway 1 discharge (Social Care
Supported Discharge), the Multi- Disciplinary Team identified that she would benefit from further
assessment and reablement in an Assessment Flat- which in her local area are situated at
Gladstone Court. However, as there was not an Assessment Flat available when she was
ready to leave hospital, interim care arrangements were made at a local Residential Care Home
and she was discharged safely to that location, the Nightingale Care Home manager was sent
the D2A Form information as part of the preliminary discharge planning and agreed that they
could meet her needs, discharge went smoothly.
7. The transfer from Nightingale Care Home to the Assessment Flat was not satisfactory as
highlighted in HM Coroner’s report, the Local Authority policy and guidance was not followed in
terms of ensuring that arrangements were in place for Mrs Spencer’s medication, and recording
of information regarding the care arrangements required This has been addressed via a
Safeguarding Adults Enquiry (Sec. 42, Care Act 2014), with recommendations and action plan
implemented (please see para.11).
Partnership working and Service Improvements
8. To ensure continued quality assurance and service improvements there are weekly Multi-
Disciplinary Workshops as part of the Integrated Care System Discharge to Assess Planning
and Service Provision. This includes a regular review of Transfer of Care Hubs and Multi-
Disciplinary Team working practices. Each month there is a focussed workshop on each
Pathway 1-3 and then a more strategic workshop as part of this agreed work plan for the
Integrated Care System. These workshops include senior operational and strategic
representatives from all key partner agencies and is key to partnership working and
collaborative culture to improving hospital discharge for people and their carers/families.
9. At a more operational level, the Transfer of Care Hubs hold weekly audits and reflective
discussions of hospital discharges that have gone well or where improvements are required.
10. Another key improvement for Hospital Discharge planning across the Integrated Care System
been the implementation of a shared dataset which tracks people through their hospital
admission and pathway out of hospital. This dataset and dashboard is used by NHS and LA
partners to ensure that all people leaving hospital are supported to do so in as timely and safe a
manner as possible.
Nottinghamshire County Council Service Improvements
11. The LA recognises that improvements have been required in the clear and accurate sharing of
up-to-date information for admission to the Assessment Flats, as illustrated by Mrs Spencer’s
situation. To ensure that the risk of any future breakdown in communication is mitigated, a new
process and referral / assessment form has been implemented for all people moving into
Assessment Flat accommodation. This process is for hospital and community admissions into
the service. The assessment form outlines the person’s care and support needs, any risks and
updated medical information including medication. This is recorded on the Social Care
Electronic Record and shared with the care provider at Gladstone Court which is Fosse
Healthcare.
12. There are also weekly meetings for the Discharge to Assessment Team Managers from the
Local Authority where practice is reviewed, and improvements discussed and shared across the
service.
The systems in place in respect of discharge to assess patients do not appear to ensure a
smooth transition between care facilities, especially when transfers are arranged at pace. In
particular, they do not appear to ensure that all involved have the information they require
to contribute effectively to the transfer process.
13. The LA would expect that the process described above is followed regarding hospital discharge,
with information shared about a person’s care and support needs prior to any transfer to a
different care provision or arrangements (whether at home or in a 24-hour care setting). This
includes the care requirements, risk assessment and mental capacity / best interests’
information. As explained above, whilst the Local Authority has a clear process in place for
arrangements by LA Social Care staff for people moving between care facilities, this was not
robust followed in the case of the arrangements for Mrs Spencer and her move to Gladstone
Court. This process has been reviewed and improved in order ensure a more robust transfer
arrangements process for people requiring this service in the future.
Yours sincerely
Corporate Director – Adult Social Care and Health
Nottinghamshire County Council
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