Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0346, written 27 Jun 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Jun 2024 |
|---|---|
| Reference | 2024-0346 |
| Deceased | Norman Leadbeater |
| Coroner | Catherine McKenna |
| Coroner area | Manchester North |
| Category | Hospital Death (Clinical Procedures and medical management) 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: , Director, Evolve Services, Bury Business Centre, Unit 23, Kay Street, Bury, BL9 6BU 1 CORONER I am Catherine McKenna, Area Coroner for the Coroner area of Manchester North 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 3 INVESTIGATION and INQUEST On 24 January 2024 an investigation into the death of Norman Leadbeater was commenced. The investigation concluded at the end of the inquest on 27 June 2024. I recorded a conclusion of Natural Causes. The medical cause of death was 1a) Aspiration Pneumonia 1b) Parkinsons Disease 2) Liver Cancer 4 CIRCUMSTANCES OF DEATH Norman Leadbeater had a past medical history of advanced Parkinsons disease, vascular dementia and presumed liver cancer. Following a swallowing assessment on 10 November 2023, he was advised to have thickened fluids to prevent chest aspiration. He was admitted to Fairfield General Hospital on 27 November and diagnosed with aspiration pneumonia secondary to Parkinsons disease. His medications were altered to liquid and dispersible forms. He was readmitted to hospital on 7 January and diagnosed with a further aspiration pneumonia. Despite treatment, he deteriorated and died on 14 January 2024. 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 Leadbeater had been in receipt of domiciliary care from Evolve Services since October 2023. The care included the administration of medication. When a concern was raised that the carers had not been thickening fluids appropriately, the Community Commissioning Team at Bury Council undertook an investigation and found that the prescribed thickener was not listed on the Medication Administration Record (MAR) and that the care plan in place for Mr Leadbeater did not contain sufficient detail for care staff to safely and correctly administer thickened fluids. In February 2024 and following its investigation into the concerns regarding Mr Leadbeater’s care, Bury Council Community Commissioning Team recommended that Evolve Services undertake a number of remedial actions. This included an immediate management audit of MAR for those service-users in receipt of medication support and liaison with GPs and Pharmacists to ensure that the medication listed for each service-user is up to date and accurate. The Court heard that four and half months since the recommendation was made, Evolve Services have not yet completed the management audit of MAR for those service users in receipt of medication support. The representative from Evolve Services who attended the inquest was unable to provide the Court with a timescale for completion of this work or the number of service users this affects. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe each of you respectively 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 23 August 2024 I, the Area 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 namely:- • The family of the Deceased • Bury Adult Social Care • The Care Quality Commission • Bury Integrated Care Partnership 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 from. 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. - Date: 27 June 2024 Signed:
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.
EVOLVE-Supporting Prospects
Unit 23, Bury Business Centre
Kay Street
Bury BL9 6BU
E-mail
21st August 2024
Dear Catherine McKenna,
RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE
DEATHS
Furthermore, to your letter dated 27th of June 2024 which contained the
Section 28, please refer to my response to the report under paragraph
7, Schedule 5, of the Coroner’s and Justice Act 2009 and Regulations 28
and 29 of the Coroners (Investigations) Regulations 2013, following the
death of Norman Leadbeater on 14th of January 2024.
Thank you for your input at the inquest and also for your identification
of the matter of concern regarding the audit of MAR sheets for service
users.
Since the Section 28 was issued to Evolve, the company have taken
many remedial steps to address the content of your letter. The current
RM has completed an audit of all MAR sheets for all the service users
and the report is attached for your attention. Attachment 1
After many discussions with our in house senior team, and with our
Contracts Officer at Bury Adult Services,
, and also with other
, who is the Medication Lead for
professionals, namely
Bury Adults Services, hence the improvements include: the Staff
Induction has been revisited and greatly improved, with additional
training, which covers the role of the SW in more detail, the Induction
period includes more observations of staff during their shift, by other
senior staff.
The Care Plans have been redefined inclusive of more details around the
client's needs, choices and preferences, refer to attachment 2, also the
training resources have been greatly updated, with an external training
provider brought in, to improve the training content and provision, there
is increased medication observations for staff, and now all staff have the
Care Certificate and NHS training on Administering Medication,
attachment 3,which was recommended by
the four staff members and remaining staff members will aim to
complete by the 6th of September 2024. We will ensure this training is
refreshed every 12 months as our standard procedure. The Medication
Lead for Bury Adult Services,
has visited the office with
has also been completed
, our Care Officer, this proved to be a very helpful meeting as
has given further direction and guidance on how to improve our
medication practices and assist the company and the staff to practice
safe medication, all policies have been rechecked and updated now, our
recruitment will be more detailed now.
, who replaced the previous RI, will undertake the Registered
Manager Award, he will be enrolled and will complete with the current
training provider that the RM, is training with. His role will involve more
time in the office, but he will do ad hoc quality checks on staff and these
checks will be recorded also. The exiting RI will still have involvement in
the service until needed.
There will be monthly staff meetings whereby staff will be encourage
and will be paid to attend, all discussions will be recorded and sent out
to staff in a timely manner, as regards to the DBS for staff, then to ease
the process, all staff are enrolled on the update service now and the
checking of log sheets is managed also by ensuring that all entries are
checked for accuracy and content.
The recent improvements made on handling, manging and administering
medication safely and to ensure safe and effective delivery of care
services for service users. The office now has a full list of all pharmacies
that our clients get their medications from and a full list of all GP
surgeries, from this list our communication has greatly enhanced our
practices. Refer to attachment 4
The improvement measures are reflected through the implementation of
best practices, enhanced training via FLEXEBEE delivered online on
Medication administration, Speech and Language Therapy
training also known as SALT, and Care Certificate containing 15
standards, which are:
1-Understand Your Role
2-Your Personal Development
3-Duty of Care
4-Equality and Diversity
5-Work in a Person-Centred Way
6-Communication
7-Privacy and Dignity
8-Fluids and Nutrition
9-Awareness of Mental Health, Dementia and Learning
Disability
10-Safeguarding Adults
11-Safeguarding Children
12-Basic Life Support
13-Health and Safety
14-Handling Information
15-Infection Prevention and Control
All staff have completed the above training now. Some staff were
offered group sessions where they attended the office and conferred
with the RM and other staff, to learn effectively about the role. Refer to
attachment 5
, and after meeting with the Medication
, as directed by
Further to regular meetings with our Care Officer from Bury Adult
services,
Optimisation Team,
sheets are printed now, the introduction of printed MAR sheets, which
will be from either the office or the chemist, this will reduce medication
errors and ultimately provide better outcomes for service users. Refer to
attachment 6
, all client MAR
To ensure that safe medication is prioritised at all times, the MAR
sheets will be continuously audited on a regular basis, after they are
returned to the office.
Staff were informed of the outcome of the Inquest, in particular, the
Section 28 applicable and the changes that were required to improve
our practices and they were kept aware of the need to improve training,
communication and their recording on the MAR sheets. The above was
discussed with the individual staff that attended to NL as well as in other
staff meetings, where other matters were raised like accuracy of log
entries, being mindful of client preferences on each visit and not to
assume their choices etc. This meeting was helpful in sharing
information and in outlining plans to ensure that staff comply with our
Action Plan and all concerned are working towards the same goals.
Yours sincerely
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