Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0495, written 10 May 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 May 2024 |
|---|---|
| Reference | 2024-0495 |
| Deceased | Terence Manning |
| Coroner | Andrew Cousins |
| Coroner area | Blackpool & Fylde |
| Category | Care Home Health 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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: HADDON COURT REST HOME, BLACKPOOL 1 CORONER I am Andrew Cousins, Assistant Coroner, for the area of Blackpool & Fylde. 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 9 and 10 May 2024, at an inquest held at Blackpool Town Hall, I returned a short form conclusion that Mr Terence Manning died as a result of an accident. I found the cause of death to be: 1(a) Hypoxic brain injury 1(b) Out of hospital cardiac arrest 1(c) Choking on a food bolus II Frontotemporal dementia 4 CIRCUMSTANCES OF THE DEATH I returned the following in box 3 of the Record of Inquest recorded: Mr Terence John Manning resided at Haddon Court Rest Home, 8-14 Haddon Road, Blackpool. Mr Manning had become a resident at Haddon Court on 29 June 2023. On 22 October 2023, Mr Manning was eating a meal at the rest home, when he experienced a choking incident. Mr Manning was taken by ambulance to Blackpool Victoria Hospital where, despite receiving treatment he died on 24 October 2023. Mr Manning had been identified to have a propensity to eat quickly, but a Speech and Language Therapy (‘SALT’) referral had not been made in his case, in circumstances where there was an opportunity for such a referral to have been made. It is not possible to say as to what the conclusion of any SALT referral would have been. 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 Terrence John Manning was a resident at Haddon Court from 29 June 2023. It was known to Haddon Court Rest Home, that Mr Manning had a propensity to eat quickly and to take food from other plates. Mr Manning was not being fed a pureed or soft texture diet, and entries to this effect in the care records are errors in the record keeping. These errors had been caused by carers carrying forward the details of records relating to other residents from entries made on the records of those other residents. It was noted in the evidence, that erroneous record keeping had taken place over a period of time and involved multiple carers. It was caused by carers transposing the records of one resident into the care records of another, leading to inaccuracies. I found that these matters gave rise to a risk of further death as the record keeping was inaccurate and did not reflect the foods being given to Mr Manning, and engaged my duty under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 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 5 July 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: The family of Terence Manning The Care Quality Commission Lancashire County Council Blackpool Council 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. 9 Andrew Cousins, Assistant Coroner for Blackpool & The Fylde Dated: 10 May 2024
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.
Dear Sir, 28th June 2024 Thank you for your report made under Regula(cid:415)on 28 dated 10 May. In the report, you outline concerns that inaccurate entries appeared in Mr Manning’s records as to the diet with which he was provided. You record concerns that such entries were errors in record keeping caused by carers “carrying forward” or transposing the records of one resident into the care records of another. At the inquest hearing, we recall that the very capability of the so(cid:332)ware concerned to allow such transposing appeared to cause you concern. In terms of our staff, we would like to reassure you that all staff have been reminded about the importance of accuracy in record keeping. We have par(cid:415)cularly reminded the staff about the risks of using what is termed the “repeat func(cid:415)onality” of the so(cid:332)ware in ques(cid:415)on, and to ensure that records are checked for accuracy a(cid:332)er use of this feature. In addi(cid:415)on, immediately following receipt of your report, we made contact with the so(cid:332)ware provider, Person Centred So(cid:332)ware Ltd. We explained the background, including our receipt of your report, and the specifics of the recording system findings about the ability to transpose entries between service users. We received the following reply from their Chief Product Officer (a copy of the original emails can be supplied if necessary): “The purpose of our care delivery solution is to give carers more time to provide care and less time spent recording care actions – we have seen huge benefit from this approach. It means that care providers have more data and better data and can make better decision. At the same time, we strive to support a proper recording with small number of mistakes done by the personnel. The “repeat functionality” is designed to make repetitive tasks and care actions quicker and easier to record. That's very beneficial if multiple residents are taking part in one activity - e.g. physical exercise. A carer may have supported multiple residents with the same care, and thus benefit from being able to repeat the same action for one resident to another; there remains however the responsibility of the user to ensure that the care record reflects the care provided. It should also be noted that the care is record ‘post the care interaction’ and would not therefore have been used to determine how a resident will have their food prepared. It is important that carers are encouraged to record the most accurate and person-centred records as possible. Based on your input, we will review the repeat functionality in detail and consider certain categories of care to be removed from the repeat functionality. That would force users to individually report the details for each resident in those selected categories. I hope this helps with the response to the coroner and addresses any concerns they have. We believe that Haddon Court Rest Home (Haddon Court Ltd) has taken robust measures to ensure records at the home meet the standards rightly expected from legal, professional and regulatory perspec(cid:415)ves. We have also responded as fully as we are able to in rela(cid:415)on to bringing this ma(cid:425)er to the a(cid:425)en(cid:415)on of and influencing the so(cid:332)ware provider. I understand that they are currently working on the func(cid:415)onality that will help to reduce the risk of erroneous recording. Should you require any further informa(cid:415)on or have any further concerns, please let me know. Yours sincerely, Director Haddon Court Ltd
See every Prevention of Future Deaths report matching Care Home Health related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.