Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0141, written 14 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 | 14 Mar 2024 |
|---|---|
| Reference | 2024-0141 |
| Deceased | Victor Costello |
| Coroner | Jo Wharton |
| Coroner area | Teesside and Hartlepool |
| 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: Prevention of Future Deaths report
Victor Valentine Costello (died 23rd February 2020 )
THIS REPORT IS BEING SENT TO:
(Chief Executive)
Stockton Care Limited
Suite 20, Durham Tees Valley Business Centre
Orde Wingate way
Stockton-on-Tees
TS19 0GD
1 CORONER
I am: Jo Wharton
HM Assistant Coroner for Teesside & Hartlepool
The Coroner's Office
Middlesbrough Town Hall
Albert Road
Middlesbrough
TS1 2QJ
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 13 March 2024, I opened an investigation into the death of Victor Valentine
COSTELLO, aged 84. The investigation concluded at the end of the inquest also held
on 13 March 2024. I made a determination that death was from natural causes. The
medical cause of death was:-
• 1(a) bronchopneumonia
• 2 cerebral infarction and generalised atherosclerosis
4 CIRCUMSTANCES OF DEATH
Mr Costello was a resident at Primrose Court Nursing Home. He was taken to hospital
on the morning of the 17th February 2020 and passed away there six days later from
naturally occurring disease.
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:
Mr Costello was nil by mouth and PEG fed. His family raised concerns that Mr Costello
had told them he had been drinking water from the taps in his bathroom. Evidence was
given at the inquest by the Nursing Home Manager that such concerns were
communicated to all staff. However, further evidence given at the inquest showed that
such communication was not effective (the nurse in charge and the two care assistants
who were on duty on the morning Mr Costello was taken to hospital, all denied being
aware of such concerns).
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 the 9th 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:-
• Mr Costello’s family
• The Care Quality Commission.
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 Dated: 14 March 2024
J. Wharton
Jo Wharton
HM Assistant Coroner for Teesside & Hartlepool
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.
Primrose Court Nursing Home South Road Norton Stockton-on-Tees TS20 2TB Tel: 01642530750 Date: 26/03/2024 Respected sir/ Madam, Jo Wharton HM Assistant Coroner for Teesside & Hartlepool The Coroner’s Office Middlesbrough Town Hall Albert Road Middleborough TS1 2QJ I confirm receipt of your report to prevent future deaths report dated 14 March 2024, following the inquest into the death of Victor Costello. As an organisation we have taken your comments and following actions are being proposed to prevent future deaths: Actions We have communicated to all staff the coroner’s concern and the importance of effective communication including use of the electronic documentation system (see item below), daily handover sheets and verbal communication between shifts. We are implementing an upgraded cloud based electronic documentation system where staff can easily look at each residents’ risks, alerts, and special instructions. Responsible people Chief Executive- Operation Director- Home Manger- All nursing and senior staff Chief Executive- Operation Director- Home Manger- All nursing and senior staff Time Scale We had an all staff meeting on 22nd March 2024. We will schedule further meetings for those staff who did not attend. The full implementation of the new electronic documentation system will be on 1st June 2024. We have made sure that effective and robust handovers take place between day and night staff to include explaining risks associated with Home Manger- Ongoing. All nursing and senior staff, to oversee the effectiveness. The Home Manager & Operations Director will keep their record of ha and any shortfalls will be addressed. - On going Operations Director, will keep their record of our checks and any shortfalls will be addressed. - Chief 08/04/2024 executive. residents to include any complaints and concerns raised by family, external agencies and staff. The management will monitor handovers as part of our regular audits. We are also making sure that for all residents who are on modified diet and fluids, their risk assessments and care plans are detailed and will be shared with next of kin to make sure all the information is correct. Taking into consideration of Coroner’s comments, we have written to all service users and families about our actions. Thank you for bringing this issue to our attention. Yours Sincerely Chief Executive - Stockton Care Ltd
See every Prevention of Future Deaths report matching Care Home Health related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.