Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0482, written 6 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 | 6 Sep 2024 |
|---|---|
| Reference | 2024-0482 |
| Deceased | Emilia Allsopp |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1) Secretary of State for Health and Social Care 1 CORONER I am Alison Mutch, Senior Coroner, for the coroner area of South Manchester 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 17th January 2024 I commenced an investigation into the death of Emilia ALLSOPP. The investigation concluded on the 29th July 2024 and the conclusion was one of Narrative: Died from natural causes exacerbated by the complications of an accidental fall. The medical cause of death was 1a) Lower Respiratory Tract Infection on the background of Left Acetabular fracture II) Dementia, Frailty, Ischaemic heart disease, Congestive cardiac failure. 4 CIRCUMSTANCES OF THE DEATH Emilia Allsopp had dementia, congestive cardiac failure and ischaemic heart disease. She had an accidental fall at the care home where she lived. Initially a fracture was not diagnosed from the x rays. However the following day her pain resulted in her returning to hospital and the fracture being identified. Surgical intervention was deemed inappropriate with her comorbidities. She was treated conservatively. Due to her limited mobility she developed a lower respiratory tract infection when in conjunction with congestive cardiac failure led to her respiratory function being significantly compromised. Her cardiac function was also further compromised by the stress of the fall, fracture and pain. She deteriorated and died at Tameside General Hospital on 15th January 2024. 5 CORONER’S CONCERNS 1 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 inquest heard evidence that Mrs Allsopp had struggled at the care home due to it being an unfamiliar environment. Her family had wanted her to remain cared for by them in a familiar home environment. They felt that if they were properly supported, home would be a safer environment for Mrs Allsopp. However Mrs Allsopp moved to the care home due to a lack of suitable community based support meaning that her family could no longer continue to care for her in the community. The inquest was told by her family that it had proved impossible to get the level of support they needed for Mrs Allsopp in the community as her dementia progressed. This created a situation where she was unsafe in her own home and had to move to a new less familiar setting. Effective dementia support for the family would have meant that could have continued to look after her at home. ACTION SHOULD BE TAKEN 6 In my opinion action should be taken to prevent future deaths and I believe you 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 1st November 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 namely Tameside General Hospital who may find it useful or of interest. on behalf of the 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. 2 9 Alison Mutch HM Senior Coroner 06/09/2024 3
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.
Our ref: HM Coroner Alison Mutch 1 Mount Tabor Street Stockport SK1 3AG By email: Dear Ms Mutch, From Minister of State for Care 39 Victoria Street London SW1H 0EU 8 November 2024 Thank you for the Regulation 28 report of 6th September 2024, sent to the Department of Health and Social Care (DHSC), about the death of Mrs Emilia Allsopp. I am replying as the Minister with responsibility for adult social care. Firstly, I would like to say how deeply saddened I was to read of the circumstances of Mrs Allsopp’s death. I offer my sincere condolences to her family and loved ones. The circumstances outlined in your report are very concerning and I am grateful to you for bringing these matters to my attention. We agree that it is important to enable people to stay well, safe and independent at home for longer by providing the right care in the right place at the right time. The government’s 10 Year Health Plan which will be published in Spring 2025 will be underlined by 3 big shifts in healthcare: • hospital to community • analogue to digital • sickness to prevention As part of the shift from hospital to community, high quality, safe, and suitable homes are a vital part of helping people stay independent and healthy for longer. To enable this in England, we continue to fund the locally administered Disabled Facilities Grant (DFG) which helps eligible older and disabled people on low incomes to adapt their homes – through practical changes like installing stair lifts or level access showers – to make them safe and suitable for their needs. At the budget, the Chancellor announced an £86 million increase to the DFG. These interventions enable older people and/or disabled adults to live more independent and healthy lives in their own home, for as long as possible. Good support within a care environment also relies on staff that are trained to a high standard. This is why, on 10 January 2024, the Department of Health and Social Care published the first part of the Care Workforce Pathway, a new national career framework, for the adult social care sector. The Pathway, along with the departments new Level 2 Adult Care Certificate qualification, have been developed to work in conjunction with existing standards and competency frameworks, including the Dementia Training Standards Framework. On 6 September 2024, the Department launched the Adult Social Care Learning and Development Support Scheme. The Learning and Development Support Scheme allows eligible employers to claim for funding for certain training courses and qualifications on behalf of eligible care staff. This includes a range of qualifications that cover the Dementia Training Standards Framework. Under CQC Regulation 18: Staffing, persons employed by the service provider in the provision of a regulated activity must receive such appropriate support, training, professional development, supervision, and appraisal as is necessary to enable them to carry out the duties they are employed to perform. I am sorry to hear that Mrs Allsopp’s family did not receive the level of support they felt they required to continue caring for Mrs Allsopp in her home. The Care Act 2014 requires local authorities to deliver a wide range of sustainable, high-quality care and support services, including support for carers. Local Authorities have duties to support people caring for their family and friends. They are also required to undertake Carer’s Assessments to support people caring for their family and friends who appear to have a need for support and local authorities are required to meet their eligible needs on request from them. The Care Quality Commission is assessing how well local authorities are meeting their duties under Part 1 of the Care Act 2014, including those relating to carers. The Health and Care Act 2022 contains significant measures for people caring for their family and friends and those they are caring for. These include: • new duties for NHS England and the new Integrated Care boards to involve carers in public engagement; • provisions for Integrated Care Boards to promote the involvement of patients and their carers and representatives (if any), in decisions relating to, prevention and diagnosis of illness, care and treatment of the person they care for; and, • a duty for NHS trusts and foundations to take any steps it considers necessary to involve patients and carers in discharge planning, where appropriate. Under the Health and Care Act 2022, NHS England and Integrated Care Boards have a duty to involve unpaid carers, such as Mrs Allsopp’s family, in care planning. NHS England will continue to look for ways to identify and support these carers. For example, within the hospital discharge process and with regard to virtual wards. I hope this response is helpful. Thank you again for bringing these concerns to my attention. Yours sincerely,
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