Margaret Austin

care UK ©

Connaught House

Janine Richards 850 The Crescent
j Colchester Business Park
Assistant Coroner for pavesed
County Durham and Darlington Essex
co4 908
For the attention of Tel 0300 130 3030
Kk.
(Coroner's officer) =

By emai
22 January 2024
Dear Madam

Inquest into the death of Margaret Austin
Regulation 28 Report to Prevent Future Deaths — Response

We write in response to your Regulation 28 report dated 27 November 2023 following the
investigation into the death of Margaret Austin. For the purpose of responding to your specific
concerns raised, | shall address each one in turn.

1. The deceased was known to be at high risk of falls and the documentation in relation to
how to manage that known high risk of falls was not comprehensive and contained
significant discrepancies as to what should, in fact, be in place, and contained no
rationale for why further measures which may have been considered appropriate were
not in situ or considered appropriate or necessary.

Stanley Park has taken a number of steps to improve documentation around assessment and
management of falls, including documentation to reflect the rationale sitting behind clinical
decision making. The steps taken are as follows:

a. The management team, with the support of the organisation's Quality Development
manager, undertook a comprehensive review of the key components of our risk
management plans and ensured that staff fully understand expectations around
completion of documents and requirements for them to be reviewed and updated.

b. Specific focus was given to bed rails assessments, ensuring that staff were
competent in utilising bed rails assessments and that they were properly reflecting
the decision making and clinical rationale in the care record.

To ensure that the learning was appropriately shared, the following steps were taken:

a. A Head of Department meeting was held on 6 December 2023 along with a senior
staff meeting on 12 December to discuss the learning from this case and the actions
required. The senior leadership team was then able to cascade the learning to the
rest of the teams through the weekly clinical review meetings.

b. The learning was also developed through 1:1 sessions with each member of staff as
part of their annual performance review discussions, held between 4 and 8

Care UK Community Partnerships Ltd. Registered in England. Registration Number 02644862
Registered office: Connaught House, 850 The Crescent, Colchester Business Park, Colchester, Essex CO4 908

December 2023. Compliance and quality in terms of falls documentation will remain
a review point in annual appraisals going forward.

2. There was no evidence that the risk management plan was reviewed as the deceased's
risks changed nor in the aftermath of documented falls.

As part of the review and discussions outlined in respect of point (1) above, during these same
processes the Home Manager has ensured that staff are appropriately recognising when
falls/risk assessments and management plans need to be reviewed and updated and that the
reviews are being carried out in a timely manner. The specific actions in relation to this point
are as follows:

a. Staff have been reminded of the trigger points for reassessment, with specific
inclusion of reassessing risk post hospital discharge and return to the home.

b. The management team are reviewing all accident and incident reports to ensure that
appropriate actions in response have been identified, including any further mitigation
steps such as sensory equipment, roll mats and requests to the GP for a secondary
care falls referral.

c. Accidents and incidents are being discussed during the weekly clinical review
meetings, with specific actions being assigned to staff members around ensuring
that the individual's assessment and management plan is updated.

d. Assessments and plans are being reviewed by the Deputy Manager to ensure
triangulation of care and to confirm that actions set in the clinical review meetings
have been fully completed.

To ensure that the learning from points (1) and (2) above has been fully embedded, an audit
was carried out (starting first with high risk patients to ensure timely review) with the purpose of
verifying that care needs have been appropriately assessed and that the assessment and
subsequent management plan is properly documented. This audit was completed on 31
December 2023 and demonstrates that staff are compliant with the standards expected of them.

There is a planned programme of ongoing audit to ensure that the improved standards are
maintained.

3. Staff training in relation to falls risk remained outstanding at the date of the Inquest for
the majority (3/4) of staff at the care home.

Whilst at the time of inquest hearing the training numbers for the specific falls risk package were
as stated, | wish to provide reassurance that all staff had undertaken their mandatory training
both in terms of induction and annual refresher training. This includes elements of falls risk
assessment and management as part of the moving and handling, emergency first aid at work
and basic life support training. At the time, the falls prevention module was development training
to enhance staff understanding rather than a mandatory requirement.

In any event, the training compliance has significantly improved since the time of the hearing
and is operating above the corporate expectation for refresher training of 90% (currently 96%
with additional sessions planned for 29 January and 14 February 2024).

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In order to maintain training completion standards going forwards, we have now incorporated
the falls specific package into the mandatory training programme to ensure that all new starters
receive this training within the 2 week induction period and then as an annual refresher for all
colleagues.

We hope that the information provided offers you the necessary assurances that Stanley Park
has taken steps to improve standards in terms of falls risk management. We also hope that the
above demonstrates that we have invested time, effort and resource into investigating the issues
you have highlighted with a view to improving care and reducing the risk of any adverse
incidents or outcomes in the future. Should you have any additional queries, we would be happy
to assist by providing further clarification.

Finally, we wish to again acknowledge the deeply sad outcome and the impact this has had on
Mrs Austin's family and friends and take a further opportunity to offer sincere condolences on
behalf of Stanley Park.

Yours faithfully,

Stanley Park Home Manager

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