Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0078, written 13 Feb 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Feb 2024 |
|---|---|
| Reference | 2024-0078 |
| Deceased | Blanche Knowles |
| Coroner | John Hobson |
| Coroner area | West Yorkshire (Eastern) |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Registered Manager, Whitkirk House, Colton Lodges Nursing Home, 2 Northwood Gardens, Colton, Leeds 2. HC-One healthcare company 3. Care Quality Commission 1 CORONER I am John Hobson, Assistant Coroner, for the Coroner area of West Yorkshire (Eastern) District. 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 31 st January 2024 I resumed an inquest into the death of Blanche Audrey Knowles, aged 91 years, which had been opened on 13th of September 2023. The investigation which has commenced on 7th September 2023 concluded at the end of the Inquest on 31 st January 2024. A narrative conclusion was recorded after the conclusion of the evidence. The medical cause of death was as follows: 1 a) Frailty of old age 2 Burns, multiple sclerosis, lschaemic heart disease, hypertension, previous stroke The Narrative conclusion was recorded as follows: 'Blanche Audrey Knowles died of frailty of old age contributed to by the effects of long- standing medical conditions and the effects of burns suffered as a result of a hot drink being accidently spilled into her lap the temperature of which had not been adequately checked'. 4 CIRCUMSTANCES OF THE DEATH Blanche Audrey Knowles had a number of health conditions and was admitted for general nursing care within Whitkirk House, Colton Lodges Nursing Home, 2 Northwood Gardens, Colton, Leeds on 7th November 2022. On 15th July 2023 she was served a drink in a beaker cup the temperature of which had not been adequately checked by a staff member. 1 The evidence heard at the inquest was that a 'warm drink' would be comprised of 'aired water' topped by cold water and that a member of staff would check the temperature of the cup/beaker by way of applying their wrist to the same. Blanche was not assisted with the beaker and it spilled causing her to suffer burns which upon assessment by a General Practitioner led to admission to hospital in the early hours of 16th July 2023. It was wholly apparent from the injuries that Blanche suffered that the temperature of the drink had not been checked in an adequate manner. The paramedics who attended Blanche on 16th July 2023 recorded that: 'The injury occurred on 1517/2023 17.30. Mechanism of injury: Burn: thermal. Pt was given hot water to drink which pt spilt between her legs. Pt had cold compress/towels applied but no active cooling by running water for 20 mins. Pt was given Paracetamol at the time. GP OOH visit arranged-Ambulance called ppst GP assessment ... ' Blanche was admitted to hospital in the early hours of 16/7/2023 and discharged on the same day. Thereafter she was treated and monitored accordingly. On 14th August 2023 paramedics were called as she was presenting with unresponsive episodes, weakness to her right side and difficulty with speech. Upon General Practitioner attendance she was prescribed antibiotics for a chest infection . Thereafter Blanche remained frail and on 29th August 2023 palliative care and anticipatory medication was discussed. On 1st September 2023 her condition deteriorated and she passed away her death being confirmed at 0930 hours. 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 MATTER OF CONCERN is as follows . - Whilst it was clear from the written and oral evidence provided to the inquest that measures had been implemented to address the risks from hot drinks, for example by the purchase and use of thermometers, upon question ing , the matter of the importance of assisting an ind ividual who has suffered burns by way of 'cooling by running water' as noted by the Ambulance staff did not appear to have been adequately conveyed to staff, be that through training or by way of clear communication as operational matters/requirements in the nursing care context. The burns suffered by Blanche contributed to the cause of her death and whilst it was not established that the recorded failure to apply 'cooling by running water' to her injuries would have made a material difference, I remain concerned that the clear importance of applying 'cooling by runn ing water' does not appear to be proactively flagged in relevant policies/procedures or by active practica l/operational communications to staff. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action . 7 YOUR RESPONSE You are under a duty to respond to th is report within 56 days of the date of this report, namely by 9th Aoril 2024 I, the Coroner, may extend the period. 2 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, to Blanche Knowles' family and the HC-One healthcare company. I have also sent it to the Care Quality Commission who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. 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 13th February 2024 John Hobson Assistant Coroner 3
2 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.
Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA www.cqc.org.uk HM Coroner's Office Att: John Hobson Assistant Coroner His Majesty’s Coroner’s Office The Coroner’s Courts Burgage Square Wakefield WF1 2TS 08 March 2024 Dear Mr. Hobson, Thank you for sending CQC a copy of the prevention of future death report issued following the death of Blanche Audrey Knowles. CQC has contacted the provider HC-One No.1 Limited, Colton Lodges Care Home, to request written confirmation and evidence of the action they have taken to date following this death and any additional action they intend to take in response to the prevention of future death report. We note the legal requirement upon the following individuals and organisations to respond to your report within 56 days: 1 The registered manager, Whitkirk House, Colton Loges Care Home, 2 Northwood Garden, Colton Lodges, Leeds 2. HC-One Healthcare company 3. Care Quality Commission We are responding as directed. Having received your report, the CQC took steps to request information and seek assurance from the provider regarding the concerns within the report. CQC have requested the following information and documents from the provider: 1. First aid policy updated. 2. Assurances and evidence that all staff have been made aware of the updated policy and appropriately trained to implement it. 3. Assurances and evidence if there have been any incidents of burns in the last 12 months, actions taken and outcome. 4. Assurances and evidence of any lessons learns, or other actions you have taken since Mrs Knowles’s death to ensure people living at Colton Lodges are safe. In additional, we have requested, received and reviewed the following documents: 1) Mrs. Knowles’ mental capacity assessment for the decision to live at Colton Lodges Care home, and receive care and treatment as required, dated 12/12/22. 2) Mrs. Knowles’ safer handling risk assessment and care plan dated 13/12/22. 3) Mrs. Knowles’ eating and drinking care plan dated 16/07/23 and monthly reviews completed. 4) Mrs. Knowles’ diet and fluid notification form completed on 04/08/23 and reviewed 04/11/23. 5) Mrs. Knowles’ communication care and support plan dated 11/12/22. 6) Mrs. Knowles’ eating and drinking risk assessment dated 23/12/22. 7) Mrs. Knowles’ care records, professional records between 10/11/22 and 29/8/23. 8) Mrs. Knowles’ drinking hot boiled water/aired water 18/07/23. 9) Mrs. Knowles’ daily notes between 01/08/23 and 01/09/23. Since Colton Lodges Care Home registration, CQC have discharged its regulatory function through ongoing review of enquiries and notifications, direct monitoring activity and inspections. For ease we will set out all the inspections undertaken since registration. • • • Inspection completed on 17 and 18 July 2018, overall rating Requires Improvement, breach in regulation 19 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Link to inspection report: 4286bbc7-2eab-4125-90f0-6d5530f8a6fb (cqc.org.uk) Inspection completed on 5 and 13 March 2020, overall rating Requires Improvement, breaches in regulations 12 (Safe care and treatment) and 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Link to inspection report: 86dc7ae6-0c9d-4885- b7ba-ae0d20b7193a (cqc.org.uk) Inspection completed on 4 and 10 May 2023, overall rating Requires Improvement. Link to inspection report: bdc41bc8-6fa5-46ff-a1a5- 20db3732221a (cqc.org.uk) CQC note the concerns outlined in section 5 of the Regulation 28 report. Action CQC intends to take is to complete an assessment within the new Single Assessment Framework, focusing on the relevant Quality Statements, within the next 3 months. If CQC deems insufficient progress has been made by the Trust or if there is risk to service users, CQC will consider discharging its regulatory functions. Thank you in advance for your assistance. Yours sincerely Operations Manager
FAO: Mr John Hobson, Assistant Coroner 28th March 2024 Dear Sir, Re: Regulation 28 Report to Prevent Future Deaths Further to the inquest touching the death of Blanche Audrey Knowles, as heard on 31 January 2024, and the corresponding Regulation 28 Report to Prevent Future Deaths of 13 February 2024, please find enclosed the response on behalf of Whitkirk House, Colton Lodges Nursing Home, 2 Northwood Gardens, Colton, Leeds. The Learned Coroner identified the following matters of concern: • Whilst it was clear from the written and oral evidence provided to the inquest that measures has been implemented to address the risk from hot drinks, for example by purchase and use of thermometers, upon questioning the matter of the importance of assisting an individual who has suffered burns by way of cooling by running water, as noted by the attending ambulance staff, did not appear to have been adequately conveyed to staff, be that through training or by way of clear communication as operational matters/ requirements in the nursing care context. • The burns suffered by Blanche Audrey Knowles contributed to the death and whilst not established that the recorded failure to apply cooling by running water to her injuries would have made a material difference, I remain concerned that the clear importance of applying cooling by running water does not appear to be proactively flagged in relevant policies/procedures or by active practical/operational communications to staff. The Learned Coroner requested that Whitkirk House, Colton Lodges Nursing Home, 2 Northwood Gardens, Colton, Leeds provide a response to enable him to understand action taken by HC-One. I am providing the following response: • Our Head of Nursing has undertaken a wide review of best practice in first aid management of burns and scolds, including for people who are nursed and cared for in bed, including current NHS and National Institute for Health and Care Excellence (NICE) guidance. • We have developed a ‘Here’s How To’ guide for our staff based on best practice guidance which includes references to current NHS and NICE guidance, including guidance on the use of cool wet towels and compresses if running water is not available or where a person is being nursed and cared for in bed where the risk of moving them is higher than cooling the burn or scald with cool wet towels or compresses. HC-One T 01325 351100 F 01325 351144 Correspondence & Registered Office: Southgate House, Archer Street, Darlington, County Durham, DL3 6AH Registered in England and Wales: HC-One Limited, registration no. 07712656; HC-One No.1 Limited, registration no. 10257888; HC-One No.2 Limited, registration no. 05217764; HC-One No.3 Limited, registration no. 07417290; HC-One No.4 Limited, registration no. 07179086; HC-One No.5 Limited, registration no. 13526345; HC-One No.6 Limited, registration no. 05747558; HC-One Management Limited, registration no. 13369844. • We have issued a Safety Management Alert that has been distributed to all Home Managers which reiterates the use of robust risk assessments for residents when eating and drinking in bed, for dissemination to staff through Organisational Learning Meetings at Home level. • We have developed training on the management of burns and scalds which will be available on our local staff training site, (Touchstone). • We are developing procedural guidance on common injury types, which will include management of burns and scalds, including people who are nursed and cared for in bed. We hope the above addresses the Coroner’s concerns as raised in the Regulation 28 Report to Prevent Future Deaths. We would like to reiterate our sincere condolences to Blanche Audrey Knowles family for their loss. Yours sincerely, HC-One - Director of Safety Page 2 of 2
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