Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0647, written 26 Nov 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Nov 2024 |
|---|---|
| Reference | 2024-0647 |
| Deceased | Susan Paley |
| Coroner | Chris Morris |
| Coroner area | Manchester South |
| 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 THIS REPORT IS BEING SENT TO: The Chief Executive Officer, Harbour Healthcare Ltd., Lodge House, Dodge Hill, Stockport, SK4 1RD CORONER I am Chris Morris, Area Coroner for Manchester South. 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 INVESTIGATION and INQUEST On 18th October 2024, I opened an inquest into the death of Susan Paley who died on 11th May 2024 at Hilltop Court Nursing Home, Dodge Hill, Stockport, aged 65 years. The investigation concluded with the inquest which I heard on 22nd November 2024. A post mortem examination determined Ms Paley died as a consequence of: 1) a) Asphyxia; 1) b) Food bolus obstruction. At the end of the inquest, I recorded a conclusion of Accident. CIRCUMSTANCES OF THE DEATH Ms Paley was a resident at Hilltop Court Nursing Home who was significantly dependent on the care of others as a consequence of complex neurological problems which left her with tremors, contractures and very limited mobility. Whilst Ms Paley had previously reported swallowing problems, the outcome of her most recent Speech and Language Therapy Assessment was normal meaning no modification was required to her diet. On 11th May 2024, a Healthcare Assistant had left Ms Paley with a sandwich to eat in bed in her room. When around an hour later the same staff member returned to check on Ms Paley, she found her unresponsive. Whilst staff sought to assist Ms Paley and an ambulance was called, an attending paramedic confirmed she had died. Ms Paley died having choked on food whilst eating in her bed. 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. 1. Given Ms Paley’s significant health problems and very limited mobility, it is a matter of 2. concern that she had been left in bed without a call bell to hand which she could easily reach should she need to summon assistance; and I am concerned that care staff at Hilltop Court do not currently have a checklist in use to accompany them when checking on residents which would act as an aide-memoire / confirmatory check that residents who require any specific aids (for instance bedrails, call- bell, sensor-mats etc.) have them in place as indicated. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation 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 by 21st January 2025. 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 I have sent a copy of my report to Ms Paley’s sister on behalf of her family. I have also sent a copy to the Care Quality Commission and Stockport Metropolitan Borough Council who may find it useful or of interest. 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. Dated: 26th November 2024 Signature: Chris Morris HM Area Coroner, Manchester South.
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.
Regula(cid:415)on 28 Report To Prevent Future Deaths Response to Coroners Concerns into the death of Ms. Susan Paley who passed away on 11th May 2024 at Hilltop Court Nursing Home, Dodge Hill, Stockport Background Harbour Healthcare is a family run care provider established in 2012. Hilltop Court is owned and operated by Harbour Healthcare, it is a Nursing Home offering nursing care for up to forty-six individuals living with demen(cid:415)a. Our philosophy is quite simple, we strive to provide an excellent standard of care to our residents, trea(cid:415)ng them with complete dignity and respect. We like to call it, simply good care. Circumstances Of The Death Ms Paley was a resident at Hilltop Court Nursing Home and was significantly dependent on the care of others as a consequence of complex neurological problems which le(cid:332) her with tremors, contractures and very limited mobility. Whilst Ms Paley had previously reported swallowing problems, the outcome of her most recent Speech and Language Therapy Assessment was normal meaning no modifica(cid:415)on was required to her diet. On 11th May 2024, a Healthcare Assistant had le(cid:332) Ms Paley with a sandwich to eat in bed in her room. When around an hour later the same staff member returned to check on Ms Paley, she found her unresponsive. Whilst staff sought to assist Ms Paley and an ambulance was called, an a(cid:425)ending paramedic confirmed she had died. A postmortem examina(cid:415)on determined Ms Paley died as a consequence of: 1) a) Asphyxia. 1) b) Food bolus obstruc(cid:415)on. Ms Paley died having choked on food whilst ea(cid:415)ng in her bed, Coroners Conclusion At the conclusion of the inquest, the coroner recorded a conclusion of Accident. Coroner's Concerns 1. Given Ms Paley's significant health problems and very limited mobility, it is a ma(cid:425)er of concern that she had been le(cid:332) in bed without a call bell to hand which she could easily reach should Page 1 of 3 she need to summon assistance; and 2. The Coroner is concerned that care staff at Hilltop Court do not currently have a checklist in use to accompany them when checking on residents which would act as an aide-memoire / confirmatory check that residents who require any specific aids (for instance bedrails, call bell, sensor-mats etc.) have them in place as indicated. Response to Concern 1 Given Ms Paley's significant health problems and very limited mobility, it is a ma(cid:425)er of concern that she had been le(cid:332) in bed without a call bell to hand which she could easily reach should she need to summon assistance; Ac(cid:415)ons Taken Harbour Healthcare uses the electronic care planning system Person Centered So(cid:332)ware (PCS) and this has been in use at Hilltop Court since 2022 a All residents have a call bell risk assessment in place. This is completed on admission and reviewed monthly therea(cid:332)er or in response to significant changes in the resident’s condi(cid:415)on. This was reviewed and updated in June 2024. b The outcome of the call bell risk assessment is then communicated into a care plan which details specific measures to ensure call bell devices, where in use, are working and within reach. c These specific measures, where appropriate, are then translated into planned care ac(cid:415)ons which are communicated to staff via handheld devices. These act not only to record the care delivered, but also to act as a reminder of care ac(cid:415)ons to be completed. Therefore, ensuring call bells are in reach and func(cid:415)oning appropriately. These measures have been in place since the implementa(cid:415)on of PCS but have been revised and made more robust in terms of detailed (cid:415)me specific ac(cid:415)ons to support resident care. d The use of and response to call bells is already a feature of staff induc(cid:415)on and this has been reevaluated to ensure clear and comprehensive understanding amongst the staff team. e The above measures are being regularly reinforced during documented supervisions and staff mee(cid:415)ngs. f Harbour Healthcare have currently upgraded the exis(cid:415)ng call bell system to enable the use of more advanced, infra-red assis(cid:415)ve technology. This work has now been completed. Response to Concern 2 The Coroner is concerned that care staff at Hilltop Court do not currently have a checklist in use to accompany them when checking on residents which would act as an aide-memoire / confirmatory check that residents who require any specific aids (for instance bedrails, call bell, sensor-mats etc.) have them in place as indicated. Ac(cid:415)ons As men(cid:415)oned above, Harbour Healthcare uses the digital care planning system PCS, and this has been in use at Hilltop Court since 2022 Page 2 of 3 a The assessment of the requirements for specific aids is completed pre-admission and again on admission, therea(cid:332)er these requirements are reviewed monthly or in response to significant change in the resident’s condi(cid:415)on. b Once again, the iden(cid:415)fied needs are cascaded into care plans and then translated through to planned care ac(cid:415)ons. This is then communicated to carers via their handheld devices. This acts as an aide-memoire. This system has been in place since the implementa(cid:415)on of PCS. c PCS is already part of staff induc(cid:415)on, and this has been strengthened by the addi(cid:415)on of a PCS training module completed by all staff using this system. d The above measures are being regularly reinforced and documented during supervisions and staff mee(cid:415)ngs. All of the above measures are underpinned by the following Policies and Procedures. a Room Call Policy b Dementia Policy and Procedure c Use of Bed Rails Policy and Procedure d Pre-Admission and Admission Policy and Procedure e Person-Centred Care and Support Planning Policy and Procedure f g Communica(cid:415)on Policy and Procedure Training Policy & Procedure Regular oversight by the Regional and Quality Teams ensures that the home is opera(cid:415)ng within the QCS Policy Framework. Page 3 of 3
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