Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0466, written 21 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 | 21 Aug 2024 |
|---|---|
| Reference | 2024-0466 |
| Deceased | Beverley Stanisauskis |
| Coroner | Joanne Kearsley |
| Coroner area | Manchester North |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Co-Chairs of the Greater Manchester Integrated Care Partnership CORONER | am Joanne Kearsley, Senior Coroner for the Coroner area of Manchester North CORONER’S LEGAL POWERS | 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 INVESTIGATION and INQUEST On the 22" April 2024, | commenced an investigation into the death of Beverley Stanisauskis who died on the 18" January 2024. The investigation concluded on the 22nd July 2024. The medical cause of death was confirmed as 1a) Acute Respiratory Distress Syndrome 1b) Aspiration Pneumonia and Influenza Pneumonia 2) Gastrointestinal Bleeding and Breast Cancer The conclusion of the Inquest as that Mrs Stanisauskis died as a result of natural causes. CIRCUMSTANCES OF DEATH Mrs Stanisauskis had been admitted to Fairfield General Hospital on the 4" January 2024 from her home address. She was suffering from shock due to a significant blood loss as a result of a gastrointestinal bleed. It was also likely she was suffering from pneumonia as a result of Influenza and likely aspiration. She was transferred to the Intensive Care Unit at the Royal Oldham hospital where despite appropriate treatment she died on the 18" January 2024. On admission to hospital there was evidence of self-neglect although this was likely to have been unintentional and linked to her learning disability. At the time of her admission to Fairfield General Hospital her medical conditions were advanced and it was unlikely she would survive. In addition it was believed that she had a carcinoma of the breast which was visible and that she had not sought treatment for the same. Mrs Stanisauskis had a learning disability. She resided at home on her own. She could not read and write particularly well. She was reluctant to speak to family and contact was sporadic. Evidence suggested she had not left her home very much since 2011. Evidence revealed she needed assistance with a number of aspects of daily living including prompts as to when to shower. She did not go shopping although she could cook. Despite this she had never been referred to the community learning disability team and received no support in respect of her medical issues. She had not been seen by her GP practice for 10 years. Following the death of Mrs Stanisaiskis the GP practice who she was registered with conducted a Serious Event review and noted the lack of engagement with the practice and the length of time she had not been seen. Importantly they also reviewed their links with the learning disability team. 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:- 1. There was a lack of recognition in the primary care setting that the patient’s known learning disability may have been a factor in their lack of engagement. No attempts were made to speak to or for a doctor to the patient and there was a lack of involvement from the learning disability team. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe each of you respectively have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 16" October 2024. |, 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:- - Family of Mrs Stanisauskis | 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: 21/08/2024 Sianfal LALO y
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.
E: Date: 14th October 2024 Private & Confidential Ms. Joanne Kearsley Senior Coroner for the Coroner area of Manchester North 2nd and 3rd Floor Newgate House Newgate Rochdale OL16 1AT Sent by email to: Dear Ms. Kearsley Re: Regulation 28 Report to Prevent Future Deaths - Mrs. Beverley Stanisauskis Thank you for your Regulation 28 Report dated 21/08/24 regarding the sad death of Mrs. Beverley Stanisauskis. On behalf of NHS Greater Manchester (NHS GM), We would like to begin by offering our sincere condolences to Mrs. Stanisauskis’ family for their loss. Thank you for highlighting your concerns during the inquest which concluded on the 22nd July 2024. On behalf of NHS GM, we apologise that you have had to bring these matters of concern to our attention. We recognise it is very important to ensure we make the necessary improvements to the quality and safety of future services. During the inquest you identified the following cause for concern: - There was a lack of recognition in the primary care setting that the patient’s known learning disability may have been a factor in their lack of engagement. No attempts were made to speak to of for a doctor to the patient and there was a lack of involvement form the learning disability team. To provide a comprehensive response, NHS GM has: outlined the actions and approach taken by Yorkshire Street Surgery (the GP Practice) provided information from Heywood, Middleton and Rochdale (HMR) locality and provided an NHS GM response. 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk Actions and approach by Yorkshire Street Surgery The information below is based on the response from the Yorkshire Street Surgery (the practice) which outlines the practice policy and implementation of their action plan. Following the sad passing of Mrs. Stanisauskis, the practice organised a Learning Event to discuss with all our staff what went wrong and how improvements can be put into place. The practice also updated practice policies and protocols. The practice explained what they have in place to support patients with a learning disability: Policy & protocol - The Practice have a Learning Disability policy/protocol in place to invite patients for their annual Learning Disability (LD) review. Patient Invitations - All patients diagnosed with a Learning Disability are invited at least three times. The Practice uses various communication methods, including telephone calls, text messages, and letters. If there is no engagement after the third invitation, the Practice refers the patient to the community Learning Disability team. As part of our commitment to patients with learning disabilities, the Practice we reach out to everyone who may not be engaging or being brought to services. The goal is to connect patients with the appropriate resources and support, including encouragement to patients to consider a conversation with the duty doctor. The practice proactively refers patients with learning disabilities to our community Learning Disability nurses regarding the following services they offer: Offering interventions and support – the Practice offer interventions and support where required, such as immunisations, cancer screenings, desensitisation work. The Practice also addresses any safeguarding concerns. On a more individual level, the Practice works closely on a 1:1 basis with patients who are not attending or being brought to their annual health checks, immunisations, screenings, and other important health appointments. There are a range of checks and interventions in place, including: Assessing capacity and determining best interests. Identifying barriers that may prevent patients from attending appointments, such as literacy issues, hearing problems, anxieties, or the need for reasonable adjustments. Assisting with booking and attending appointments. Liaising with key people such as carers, family, and friends. Signposting to other services if needed. Offering home visits. Providing easy-read educational material. Undertaking health assessments. As an example of recent pro-active work, on the 11th July 2024, a Registered Nursing Associate from the Learning Disability and Health Inequalities Team visited our practice and met with the Primary Healthcare Assistant Practitioner and Primary Care Assistant Practitioner. Their focus was to ensure that the Learning Disability register is accurate and to identify patients who haven’t had their annual health check for the longest time. They support the most vulnerable and hard-to-reach patients in attending their annual health checks. Some inaccuracies were identified in patient diagnoses, and a further meeting took place on 12th September 2024 to discuss these findings. The Practice have already achieved an 86% completion rate for annual checks among our patients. Only 14% remain, and the Practice are working with the Learning Disability team to engage these patients for further action. 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk Response from HMR Locality HMR ICB’s Quality and Safeguarding Team have supported GP Practices for many years in ensuring that patients with Learning Disability received annual health checks and ensuring that patients are supported and encouraged to engage with their GP. Attached at Appendix 1 is the 21/22 LD Resource Pack provided to Primary Care in HMR. An audit was completed in 2022 and the report was submitted to the HMR Quality, Safety and Safeguarding Strategic Group and upwards to the HMR Locality Board. The report is attached to this response at Appendix 2. In February 2023, NHS Greater Manchester Integrated Care (GMIC) HMR and Rochdale Care Organisation jointly held a System Learning Event for Learning Disabilities and Autism. The ‘In My Shoes Theatre Production’ provided a presentation. All the members of the production company have learning disabilities and provided an insightful and informative view into the lives of people with LD and their interactions with Health and Social Care. The event was videoed by the Heywood, Middleton and Rochdale Communications Team in order to cascade it within NHS GM for Health and Social Care Professionals, with the intention of sharing learning experiences, and enhance knowledge and skill sets within the organisations. The following link takes to you the video hosted on YouTube (but this was not made public in view of consent restrictions) - https://youtu.be/A0npK1bXLtw said: “The Learning Disability and Autism event was very thought-provoking Councillor with lots of ideas and discussions and different ways of doing things, all with the same aim of benefitting those with learning disabilities. The strength of the meeting was we were all together in one room and this is so important, it was much more personal than a zoom meeting which we have been experiencing over the last two years and it is important we continue with these face-to-face events.” Another audit was completed in July 2024 of Annual Health checks for people with learning disabilities aged 14-25 years. The report is attached at Appendix 3. HMR are involved in lots of work across GM and a draft workplan was disseminated in Feb 2024. The workplan is attached at Appendix 4. The role of the Community Learning Disabilities team in Heywood Middleton and Rochdale is to provide health interventions to adults over the age of 18 with a diagnosed learning disability. The team is made up of healthcare professionals including nurses, Mental Health practitioner, speech and language therapist and psychiatry. The team will support adults with a learning disability with the following types of health needs relationships and education around this Unmet health needs and understanding how your health affects you Positive behaviour support Epilepsy Thoughts and feelings Communication Dysphagia How LD affects you Psychiatry. 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk In order to learn from this incident to ensure this does not happen again, the Learning Disability Team has: Employed a Health Inequalities lead practitioner. This role is to identify areas within healthcare where a person with a LD does not have the same health outcomes as the general population. Employed Primary Care Assistant Practitioners who will work alongside GP practices to validate their Learning Disabilities registers and identify those hard-to-reach individuals who have not been seen by their GP within the last 12 months or have not attended for their annual health check within the last 12 months. These practitioners will then work within the community Learning disabilities service to reach out to these individuals and support them to understand the importance of health checks, identify barriers and encourage them to receive their annual health check. NHS Greater Manchester NHS Greater Manchester have produced an improvement plan in response to the LeDeR annual report. One of the key priorities is continuing to undertake learning disability register validation and targeted support to those people on the learning disability register who may have not been seen for annual health checks. This is improving the uptake of annual health checks and health action plans across Greater Manchester each year. NHS Greater Manchester is working closely with people with lived experience and developing improved access to services such as annual health checks, cancer screening pathways, flu and COVID vaccinations. This is to ensure these pathways have reasonable adjustments in place and there are appropriate methods used for call and recall and communication. Within the improvement plan, one of the key priorities is the development of a Prevention of Adults not Brought Strategy. This strategy will look to raise awareness of reasonable adjustments, improve whole workforce education in relation to reasonable adjustments and support services to identify those at risk of not being brought to appointments. This strategy will focus on adults with a learning disability who are at risk of not being brought to appointments, however the principles can apply to all vulnerable adults who may find it hard to access services. Best wishes 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk Appendix 1 - 21/22 LD Resource Pack provided to Primary Care in HMR LD resources for GP practices 2021-22.docx 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk Appendix 2 – 2022 LDA Audit Report LDA Audit Report 2022.pdf 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk Appendix 3 - July 2024 audit of Annual Health checks for people with learning disabilities aged 14-25 years Annual LD Health Check Audit Report 2024.odt 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk Appendix 4 – GM LDA 2024/25 workplan GM LDA HI Draft workplan 24-25 Feb 24.pptx 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk
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