Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0129, written 6 Mar 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Mar 2024 |
|---|---|
| Reference | 2024-0129 |
| Deceased | John MacGregor |
| Coroner | Hugh Bricknell |
| Coroner area | Herefordshire |
| 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.
H G Mark Bricknell Senior Coroner for County of Herefordshire 6th March 2024 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: , Care Home Manager, Credenhill Court Rest Home, Hereford. 1 CORONER I am Hugh Gregory Mark Bricknell, Senior Coroner for County of Herefordshire 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. http ://www.legislation.gov.uk/ukpga/2009/25/schedule/S/paragraph/7 http://www. legislation .gov. u k/u ksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 28 April 2023 I commenced an investigation into the death of John Patrick MacGREGOR. The investigation concluded at the end of the inquest on 28 February 2024. The conclusion of the inquest was 'Narrative' - Mr MacGregor fell at Credenhill Court Rest Home on the 2nd April 2023. Substantive medical intervention did not take place until the 13th April 2023 when he was profoundly unwell. 4 CIRCUMSTANCES OF THE DEATH Patient admitted with chest pain and shortness of breath after a fall in a care home. He was found to have a left sided hydropneumothorax, fractured right proximal humerus and Ll end plate compression fracture. A chest drain was inserted and drained well on the ward and he was receiving IV antibiotics. He was reviewed by geriatricians and respiratory physicians, who assisted in optimising his management. He was also reviewed by T&O for his fracture. However, his infection markers did not improve after 7 days of IV antibiotics and IV antifungals. He became significantly more unwell with fluctuations in blood pressure and increasing oxygen requirements. A chest x-ray showed a right sided-HAP. He was already receiving the antibiotic of choice for this with no improvement and a decision was made to start him on the end of life pathway. There was concern regarding the lapse oftime from the fall to hospital admission. 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 MATTERS OF CONCERN are as follows. - Evidence was heard regarding: (a) The quality of residents care documentation and its completion . (b) Procedures regarding escalation or non-escalation following a fall and subsequent medical intervention 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you, Home Manager have the power to take such action . , Care 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 1 May 2024. 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; . I have also sent it to Herefordshire Council and the CQC 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 6 March 2024 Signature n I \ HG Mark B~ tM Senior Co1 ner: Herefor shire
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.
CREDENHILL COURT REST HOME Credenhill, Hereford, HR4 7DL 24th April 2024 HG Mark Bricknell HM Senior Coroner Town Hall St. Owen Street Hereford HRl 2PJ Dear Mr. Bricknell, Ref: John Patrick MacGregor I am writing in response to the regulation 28 report to prevent further deaths dated 6th March 2024. The following action has been taken: • Credenhill Court Rest Home no longer facilitates respite residents. After reviewing the respite care plan we feel, although affective in its short term use it is not as robust as our caredocs care planning system. • Senior care staff have been supported through weekly discussions to ensure they are confident in documenting the needs of each resident, they are able to capture everything on a day to day basis and any concerns raised are being addressed and documented. The notes are being regularly reviewed and audited. • The falls protocol has been reviewed and we believe it is affective and each fall is taken on its own merit, any concerns beyond the parameter of the protocol we seek support and guidance from the appropriate health professionals i.e. doctors or paramedics and this documented. The falls continue to be audited each month to highlight any trends and to ensure the correct professional has been contacted. Any minor fall that takes place at Credenhill Court Rest Home the senior on duty emails the GP care home ad min group and this resident is then reviewed on the weekly ward round and notes are added to their individual patient records. Each resident regardless of the severity of the fall and their capacity have 24-48 hour monitoring in the form of blood pressure, pulse and body map notes. I have reviewed our weekly ward round and a list of residents that need to be seen are emailed to the GP surgery 24 hours in advance. Once the residents have been seen we now receive a record of actions taken by the GP/ECP that visited. These actions are then added to the individual resident's health notes within their care plan and any omissions can be identified. • • The medication processes for residents taking blood thinners has been reviewed by the GP surgery and there are no concerns with the process we have in place although we ourselves have added an additional safeguard by including an alert sheet that can be found within the medication administration sheet. • In addition to our verbal handover and residents information board on display to all care staff in the office, to facilitate and capture more extensive notes for the daily records we have implemented a written daily handover sheet that care staff will complete and this will then be added to each residents daily records. • Care plans continue to be regularly reviewed and audited monthly or when required. I will carry out daily audits of the daily notes that have been written and continue to • support staff to ensure that the quality of our written documentation is upheld. If you require any further information please do not hesitate to contact me. Yours sincerely Care Manager
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