Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0481, written 3 Sep 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Sep 2024 |
|---|---|
| Reference | 2024-0481 |
| Deceased | Margaret Aitchison |
| Coroner | Nicola Mundy |
| Coroner area | South Yorkshire (East) |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
MS N J MUNDY H M CORONER SOUTH YORKSHIRE (East District) email: hmc.doncaster@doncaster.gov.uk CORONER'S COURT AND OFFICE CROWN COURT COLLEGE ROAD DONCASTER DN1 3HS Tel: (01302) 737135 Fax: (01302) 736365 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Pristine Care Group Ltd 1. CORONER I am Ms N J Mundy, Senior Coroner for South Yorkshire East 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/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3. INVESTIGATION and INQUEST On the 3rd January 2023 I commenced an investigation into the death of Margaret Aitchison. The investigation concluded at the end of the inquest . The conclusion of the inquest was: Accidental death 1a Multiple traumatic injuries 1b Fall 1c II Ischaemic heart disease and hypothermia 4. CIRCUMSTANCES OF THE DEATH Margaret Aitchison was a resident in the Broom Lane Care home. Her room was on the first floor of the Sitwell Unit. On the 15th December 2022 at around 10:30 p.m. there was a fire alarm activation. The fire service attended and established that it was a false alarm having being activated by one of the residents. They departed and the maintenance worker came to reset the alarm. There was conflicting evidence as to the resident checks carried out after the alarm had sounded and I found that there were either no or inadequate resident checks following the reactivation of the alarm and furthermore some if not all the fire exits were not checked following the alarm. Although it is not clear whether sleep checks were properly performed on a 2 hourly basis throughout the night, I was able to determine is that at some time after 6:00 a.m. carers discovered that Mrs Aitchison was no longer in her room and after a check of the premises which lasted up to 30 minutes, she was found at the bottom of an unheated stairwell leading to an external fire exit. She had somehow accessed what should have been a locked fire door on the landing area and having gone through, fell down the stairs sustaining traumatic injuries from which she died. She was hypothermic when found (the outside temperature was -5 degrees). I heard evidence that new systems are now in place for checking resident safety and fire door exits after an alarm has sounded and the system has been reactivated but one of the witnesses, who was a carer at the time of the incident and has remained at the home, said that there were still no formal checks and matters hadn't changed. 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. The evidence from a care worker who was at the home at the relevant time, and remains a care worker at the home, that there are still no formal systems for checking of residents after fire alarm activations, is at odds with the evidence I heard from the care manager that there had been comprehensive changes and a training programme implemented. I am concerned that the processes, protocols and expectations have not been effectively cascaded to those providing care to residents in homes. Accordingly, I invite you to consider the following and in particular whether there is a need for: 1. Further training of senior staff. 2. A requirement for senior staff to each put in place clear processes for staff to respond to fire alarm activations. 3. Training of carers, and any other relevant staff members, in terms of checking resident safety and fire door exits. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you Tanzeel Younas 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 29th October 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; Ward Hadaway, Rotherham Metropolitan Borough Council and Mrs Aitchison's family. 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. 3 September 2024 9. Signature Ms N J Mundy, Senior Coroner for South Yorkshire East
MS N J MUNDY H M CORONER SOUTH YORKSHIRE (East District) email: CORONER'S COURT AND OFFICE CROWN COURT COLLEGE ROAD DONCASTER DN1 3HS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: National Care Consortium Ltd 1. CORONER I am Ms N J Mundy, Senior Coroner for South Yorkshire East 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/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3. INVESTIGATION and INQUEST On the 3rd January 2023 I commenced an investigation into the death of Margaret Aitchison. The investigation concluded at the end of the inquest . The conclusion of the inquest was: Accidental death 1a Multiple traumatic injuries 1b Fall 1c II Ischaemic heart disease and hypothermia 4. CIRCUMSTANCES OF THE DEATH Margaret Aitchison was a resident in the Broom Lane Care home. Her room was on the first floor of the Sitwell Unit. On the 15th December 2022 at around 10:30 p.m. there was a fire alarm activation. The fire service attended and established that it was a false alarm having being activated by one of the residents. They departed and the maintenance worker came to reset the alarm. There was conflicting evidence as to the resident checks carried out after the alarm had sounded and I found that there were either no or inadequate resident checks following the reactivation of the alarm and furthermore some if not all the fire exits were not checked following the alarm. Although it is not clear whether sleep checks were properly performed on a 2 hourly basis throughout the night, I was able to determine is that at some time after 6:00 a.m. carers discovered that Mrs Aitchison was no longer in her room and after a check of the premises which lasted up to 30 minutes, she was found at the bottom of an unheated stairwell leading to an external fire exit. She had somehow accessed what should have been a locked fire door on the landing area and having gone through, fell down the stairs sustaining traumatic injuries from which she died. She was hypothermic when found (the outside temperature was -5 degrees). I heard evidence that new systems are now in place for checking resident safety and fire door exits after an alarm has sounded and the system has been reactivated but one of the witnesses, who was a carer at the time of the incident and has remained at the home, said that there were still no formal checks and matters hadn't changed. 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. The evidence from a care worker who was at the home at the relevant time, and remains a care worker at the home, that there are still no formal systems for checking of residents after fire alarm activations, is at odds with the evidence I heard from the care manager that there had been comprehensive changes and a training programme implemented. I am concerned that the processes, protocols and expectations have not been effectively cascaded to those providing care to residents in homes. Accordingly, I invite you to consider the following and in particular whether there is a need for: 1. Further training of senior staff. 2. A requirement for senior staff to each put in place clear processes for staff to respond to fire alarm activations. 3. Training of carers, and any other relevant staff members, in terms of checking resident safety and fire door exits. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you the power to take such action. have 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 29th October 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; Ward Hadaway, Rotherham Metropolitan Borough Council and Mrs Aitchison's family. 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. 3 September 2024 9. Signature Ms N J Mundy, Senior Coroner for South Yorkshire East
2 responses 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.
06/09/2024, 09:50:20 Subject: RE: FAO the office of Ms. Mundy- senior Coroner Sent: From: To: Cc: National Care Consortium Ltd HMC Doncaster Follow Up Flag: Follow up Flag Status: Flagged Caution! This message was sent from outside your organization. Allow sender Good morning , Thank you very much for your response-. I just want to confirm that the required documents did go to the correct person, our Chairman family portfolio. who is the nominated individual for many of the services within the National Care Consortium is our umbrella parent company and Broom Lane care home is a part of one of the sister companies within the organisation which comes under the business heading of Pristine Care Group LTD. Thank you for your assistance in this matter. Kind regards Kelly From: HMC Doncaster Sent: 05 September 2024 15:24 To: ' Subject: RE: FAO the office of Ms. Mundy- senior Coroner - National Care Consortium Ltd' Afternoon Kelly Thank you for your email Ms Mundy wishes to clarify is National Care Group part of Pristine Care and did the Reg 28 report go to the correct person. Kind regards Coroner Support Assistant Corporate Resources Doncaster Council Good afternoon I am writing to you today thank you for your correspondence and to acknowledge receipt of the letter from Ms. Mundy dated 3.9.24, along with a copy of the prevention of future deaths- Regulation 28 paperwork. Can I please respectfully request that the letter be amended to state that Broom Lane is part of Pristine Care Group LTD and not National Care consortium as stated at present. Many thanks Kind Regards, NCC Care Home Support Manager
Broom Lane Care Home Broom Lane Rotherham S60 3NW Dear Ms Mundy Your Ref Case No: Margaret Aitchison, (Deceased) DOB: 03.08.1943 – DOD: 16.12.2022 I write on behalf of Group Ltd in respect of the case heard by you regarding Mrs Margaret Aitcheson and the resulting issue of a PFD report. the nominated individual and Chair of the Pristine Care I have attached the necessary documents which I feel should answer your concerns you raised in your conclusion. when she I can confirm and agree with the statement made by my colleague gave evidence that the processes and protocols put in place after reviewing the original items are definitely in place (some of which were with immediate e(cid:431)ect) and as an organisation we are confident as we can be that any identified shortfalls have been addressed and the auditing duties carried out by the senior management team on a regular basis should highlight any discrepancies in the future. I can also confirm that a CQC inspector visited the care home only this week to review the protocols after receiving notification from your o(cid:431)ice and she was more than happy with improvements made. As always the ethos of the organisation is ensuring the safety of our residents is paramount and the lessons learnt have been cascaded to our sister services within the portfolio. I thank you and your o(cid:431)icers for your assistance in this matter. Yours sincerely Regional Manager 20/09/2024
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