Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0440, written 12 Aug 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Aug 2024 |
|---|---|
| Reference | 2024-0440 |
| Deceased | Douglas Armstrong |
| Coroner | David Lewis |
| Coroner area | Liverpool and Wirral |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Community health care and emergency services 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Medequip UK 1 CORONER I am David LEWIS, Assistant Coroner for the coroner area of Liverpool and Wirral 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 17 January 2024 I commenced an investigation into the death of Douglas ARMSTRONG aged 88. The investigation concluded at the end of the inquest on 12 August 2024. The conclusion of the inquest was that: On 16 December 2023 the Deceased had an unwitnessed fall at his home address. He sustained a fractured neck of femur, but this was not identified either by two responders from an agency or by the district nurse who attended. As a result his arrival at Arrowe Park Hospital, Arrowe Park Road, Wirral hospital was delayed by around 18 hours, and it is likely that his subsequent surgery was similarly delayed, adding slightly to the mortality risk. He died at the hospital on 5 January due to aspiration pneumonia, which resulted from the accidental injury sustained in the fall. It is unlikely that the delay in hospital admission either caused or materially affected the timing of his death. 4 CIRCUMSTANCES OF THE DEATH On 16 December 2023 the Deceased had an unwitnessed fall at his home address. He sustained a fractured neck of femur, but this was not identified either by two responders from an agency or by the district nurse who attended. As a result his arrival at Arrowe Park Hospital, Arrowe Park Road, Wirral hospital was delayed by around 18 hours, and it is likely that his subsequent surgery was similarly delayed, adding slightly to the mortality risk. He died at the hospital on 5 January due to aspiration pneumonia, which resulted from the accidental injury sustained in the fall. It is unlikely that the delay in hospital admission either caused or materially affected the timing of his death. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) Following his fall at home the Deceased was visited by two representatives of the care agency. They did not appreciate that he had suffered a fractured neck of femur. They placed more reliance than was justified upon his assertion that he had not hurt himself and was not in pain. The information supplied during their verbal communication with the Regulation 28 – After Inquest Document Template Updated 30/07/2021 ambulance service did not result in the latter appreciating the need for a personal attendance or visual assessment. Fractured neck of femur is a common consequence of falls in the elderly and requires prompt attention. Those providing a response system should have the skills, knowledge and training necessary to identify the problem or to appreciate that they cannot do so, and to communicate the limits of their diagnostic ability to the ambulance service. I was told that the responders acted in accordance with their existing training and have had no additional training since these events, nor was I told that any is planned. I am concerned that responders attending a similar call might be unable to assist effectively and would appreciate their employers addressing this by considering whether opportunities exist to improve the situation. 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 October 07, 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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: 12/08/2024 David LEWIS Assistant Coroner for Liverpool and Wirral Regulation 28 – After Inquest Document Template Updated 30/07/2021 Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Medequip Unit 2 The Summit Centre Skyport Drive Harmondsworth West Drayton UB7 0LJ Tel: www.medequip-uk.com PRIVATE AND CONFIDENTIAL Our ref: 7th Oct 2024 Sophie Davies The Coroner’s Office Liverpool and Wirral Area Gerard Majella Courthouse Boundary Street Liverpool L5 2QD RE: Your Ref: Dear Sophie Following the coroner's inquest held on 12 August 2024, we have reviewed the matter referenced above and are providing our formal response in respect to Regulation 28 – Preventing Future Deaths. We have outlined the key actions taken to address the concerns raised: Action 1: Review and Update to Emergency Responder Procedures A thorough review of Medequip’s Responder Service procedures was conducted following the investigation of the incident. This review was completed on 1 July 2024 and included the implementation of a new digital form for recording responder visits and conducting risk assessments for both service users and the environment. These updated procedures are designed to improve the safety and efficiency of responder visits. Action 2: Implementation of Digital Responder Forms To replace the previous paper-based system, we developed digital forms for responder visits in accordance with the TEC Services Association’s Quality Standards Framework. These digital forms incorporate a comprehensive risk assessment to ensure responders are effectively guided throughout their visit. They include follow-up actions, signposting, safeguarding measures, and detailed recording of service user welfare. Additionally, the digital form features a ‘top-to-toe’ physical assessment to help identify potential injuries more thoroughly. This system went live on 1 July 2024, aligned with the revised procedures. Action 3: First Aid Training It was identified that all responders required updated First Aid training. This training was completed and delivered to all responders by 1 April 2024 to ensure they are equipped to provide immediate care when necessary. Medequip Assistive Technology Ltd. Company Registration No: 4198824 Registered Address: Unit 2, The Summit Centre, Skyport Drive, Harmondsworth, West Drayton, Middlesex, UB7 0LJ Action 4: People Manual Handling Training for Responders A bespoke People Manual Handling Training program has been developed by Medequip Connect. This program, led by a dedicated and qualified trainer, has been designed to enhance the safety and effectiveness of lifting service users, as well as the safe operation of lifting equipment. The training was created in collaboration with Medequip Connect’s National Clinical Lead and includes accredited content. The roll-out of this training is currently underway, with full completion expected by the end of January 2025. We trust these actions address the concerns outlined in the inquest and demonstrate our commitment to preventing future incidents. Yours sincerely, Head of Safety, Health, Environment, Quality (SHEQ), Governance and Training Medequip Assistive Technology Ltd. Company Registration No: 4198824 Registered Address: Unit 2, The Summit Centre, Skyport Drive, Harmondsworth, West Drayton, Middlesex, UB7 0LJ
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