Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0661, written 2 Dec 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Dec 2024 |
|---|---|
| Reference | 2024-0661 |
| Deceased | Gloria Linton |
| Coroner | Oliver Longstaff |
| Coroner area | West Yorkshire (East) |
| 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.
OFFICE OF THE
SENIOR CORONER
for the County of West Yorkshire
(Eastern District)
His Majesty’s Coroner’s Office
The Coroner’s Courts
Burgage Square
Wakefield WF1 2TS
Telephone:
Email:
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Lifeway Care Ltd, Unit 7, Suite 705, Ashbrooke Pary, Parkside Lane, Leeds LS11 5SF
CORONER
I am Oliver Longstaff, Area Coroner for the Coroner area of West Yorkshire (Eastern District)
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.
INVESTIGATION and INQUEST
On 30/08/2022 I commenced an investigation into the death of Gloria Linton, aged 77. The
investigation concluded at the end of the Inquest on 28/11/2024. The conclusion of the Inquest
was a narrative conclusion, recording the cause of death as 1a) Pneumonia 1b) Rib fractures
due to entrapment in a commode 2) Covid 19 infection, Cerebrovascular Disease, Ischaemic
Heart Disease, Osteoporosis, Oropharyngeal Dysphagia (Clinical Diagnosis), and stating in
summary that Gloria Linton died from the effects of medical complications arising from bilateral
fractures of the posterior and lateral aspects of her ribs after she had become trapped in the
aperture of a commode seat while being tended by carers.
CIRCUMSTANCES OF THE DEATH
On 06/08/2022 carers had taken Gloria Linton in a wheeled commode into her wet room, where
she had toileted and been showered while still seated in the commode. Carers assisted her to
stand using manual handling techniques so that she could be dried and have moisturising and
barrier creams applied to her. Gloria began to open her bowels again and carers attempted to
sit her down on the commode, placing her on the commode seat at an angle such that her left
leg passed through the gap at the front of the commode seat and her right leg followed,
effectively trapping her in the commode seat’s central aperture. She passed further down into
the aperture, becoming trapped just below her chest. While trapped she sustained numerous
osteoporotic fractures to the back and sides of both her ribcages, through either or both of her
own efforts to free herself and the process of being extracted from the commode by the
attending emergency services. The rib fractures were found at post mortem to have been a
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direct contributing cause of the pneumonia that was the immediate cause of Gloria’s death in
hospital on 23/08/2022.
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. –
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(1) The care plan in place for Gloria required her to be transferred between sitting and
standing by two carers using a piece of equipment called a Rotanda.
(2) Prior to the events of 06/08/2022 it had been noted and reported that carers were not
routinely using the Rotanda, and it had been reiterated to carers by the relevant
Community Health Trust that the Rotanda should be used, notwithstanding Gloria’s
reluctance.
(3) On 06/08/2022 the carers did not use the Rotanda either to support Gloria to stand so
she could be dried and her skin moisturised or to assist her to sit back on the commode
when her bowels opened as she was being dried.
(4) Had the Rotanda been used to assist Gloria to sit, it is unlikely that she would have been
placed on the commode seat at an angle such that her legs could have passed through
the opening at the front of the commode seat.
(5) The carers were employed by Lifeway Care Ltd.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your organisation
has 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 27/01/2024. 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.
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
, Yorkshire Ambulance Service, Leeds Community Healthcare Trust. I have also
sent it to the Care Quality Commission who may find it useful or of interest.
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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.
Signed:
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OLIVER LONGSTAFF
Area Coroner
West Yorkshire (E)
Date: 2 December 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.
DWF Law LLP 1 Scott Place 2 Hardman Street Manchester M3 3AA DX 14313, Manchester T +44 (0)333 320 2220 F +44 (0)333 320 4440 www.dwf.law Mr Oliver Longstaff Area Coroner for West Yorkshire His Majesty's Coroner's Office The Coroner's Courts Burgage Square Wakefield WF1 2TS By email only: Your Ref: Our Ref: Date: Please ask for: E-mail: Mobile: Please quote this when replying 6 January 2025 Dear Mr Longstaff, Inquest into the death of Gloria Linton - Regulation 28 Report to Prevent Future Deaths – Response by Lifeway Care Limited This response is provided to Mr Oliver Longstaff, Area Coroner for West Yorkshire on behalf of Lifeway Care Limited following the inquest into the death of Mrs Gloria Linton. Coroner's concerns The Coroner's concerns dated 2 December 2024 were as follows: 1. The care plan in place for Gloria required her to be transferred between sitting and standing by two carers using a piece of equipment called a Rotanda. 2. Prior to the events of 6 August 2022 it had been noted and reported that carers were not routinely using the Rotanda, and it had been reiterated to carers by the relevant Community Health Trust that the Rotanda should be used, notwithstanding Gloria's reluctance. DWF Law LLP is authorised and regulated by the Solicitors Regulation Authority (SRA) as an Alternative Business Structure The rules of the SRA are available at www.sra.org.uk/handbook/ The term 'Partner' is used to refer to a Member of DWF Law LLP or an employee or consultant with equivalent standing and qualifications A list of Members of DWF Law LLP and of Non-Members who are designated as Partners is open to inspection at its registered office located at 1 Scott Place, 2 Hardman Street, Manchester, M3 3AA DWF Law LLP is listed on the Financial Services Register as an Exempt Professional Firm, able to carry out certain insurance mediation activities (regulated by the Solicitors Regulation Authority). 1 3. On 6 August 2022 the carers did not use the Rotanda either to support Gloria to stand so she could be dried and her skin moisturised or to assist her to sit back on the commode when her bowels opened as she was being dried. 4. Had the Rotanda been used to assist Gloria to sit, it is unlikely that she would have been placed on the commode seat at an angle such that her legs could have passed through the opening at the front of the commode seat. 5. The carers were employed by Lifeway Care Ltd. Response - Action taken As the Coroner is aware, immediately following the incident, all carers were provided with a refresher course in Moving and Handling, as well as refresher training on Safeguarding, Effective Communication and Reporting concerns to the Registered Manager/Office. Since the Inquest into the death of Mrs Linton, further training has been carried out with all staff in order to ensure that carers strictly adhere to care plans with regards to prescribed equipment in the future and do not use their own discretion or judgment to determine whether or not a piece of equipment ought to be used (regardless of any desire to fulfil a service user's wishes which may involve not using prescribed equipment or any determination by the carer that it would be the safer option not use a prescribed piece of equipment). The attached "Staff Declaration of Compliance with Care Plan and Equipment Use" document details the additional training that has been provided in this regard. It has been signed off by all staff to acknowledge their understanding and commitment to the use of prescribed equipment. Any new staff will be provided with this training. In addition to the additional training provided to staff, Lifeway Care Limited has also arranged via its online monitoring system providers for a banner to be inserted to the top of the online app used by its carers. This means that each time a carer attends a care visit and accesses the app, they are reminded of the following message "Attention: ensure you follow care plan and use prescribed equipment in all situations". As was the case prior to the Inquest into the death of Gloria Linton, Lifeway Care Limited will continue to carry out regular spot checks to ensure compliance with all its policies, including adherence to the use of prescribed equipment. It will also ensure that refresher training is provided regularly in the future. We trust that the above action taken by Lifeway Care Limited has satisfied the Coroner's concerns but should the Coroner have any further queries, please do not hesitate to contact us. Yours sincerely Associate DWF Law LLP
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