Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0002, written 2 Jan 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Jan 2025 |
|---|---|
| Reference | 2025-0002 |
| Deceased | Victor Knowles |
| Coroner | Charlotte Keighley |
| Coroner area | Cheshire |
| 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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Henning Hall Nursing Home 2. Springcare Care Homes Ltd 1 CORONER I am Charlotte Keighley, Assistant Coroner, for the coroner area of Cheshire. 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 the 7th February 2024, I commenced an investigation into the death of Victor William Knowles. Victor died on the 20th January 2024. He was 79 years old. The investigation concluded at the end of the inquest on the 12th December 2024. The medical cause of death was confirmed as 1a Osmotic Demyelination Syndrome caused by 1b Hypernatremia due to 1c Dehydration; and 2 Frailty of old age. I recorded a narrative conclusion that Victor died of a rare neurological complication of hypernatremia as a consequence of dehydration and malnourishment and that Victor’s death was contributed to by Neglect. 4 CIRCUMSTANCES OF THE DEATH On the 12th of December 2023, Victor was admitted to Henning Hall Nursing home as a short-term placement to inform in his long-term care planning. At the time of his admission Victor lacked mental capacity and was identified as being at high risk of dehydration and malnutrition, requiring assistance to promote his fluid and oral intake. Plans were put in place for his weight to be monitored and recorded weekly. The Court heard evidence that on the 2nd January 2024, Victor was seen by his GP and although there was some discussion in respect of his poor dietary intake, the GP was not informed of the 5kg of weight that Victor had lost within the preceding 12 days, nor was the GP provided with the details of the limited amount of fluid that Victor was taking at that time. On the 4th January 2024, Victor was booked onto the GP triage list following concerns being raised by staff in respect of his fluid and oral intake. The Court heard evidence that the GP made three attempts to contact the Home but there was no answer with no follow up being made by the Home in respect of the missed appointment. The Court heard evidence from the GP that Victor was seen again on the 9th January 2024 by which time he had become too frail for his weight to be measured. At the time of the review, Victor’s fluid intake was very low but the details recorded by the Home 1 were not provided to the GP so as to form part of his assessment, nor was the GP informed that Victor had become too frail to weigh. The Court heard evidence that on the 11th January 2024, Victor was reviewed via telephone by the community dietician who was informed that Victor’s weight had been steady since early December but that he was refusing to eat and required encouragement to drink. It was accepted that the information in respect of Victor’s weight was not accurate given that he had lost 5kg since his admission to the Home. Later that day, a telephone call was made by the Home to the next of kin, in which it was reported that Victor was very poorly, his clinical observations indicating very low blood pressure and a high pulse rate. Evidence was heard that attempts were made that day to contact both the GP and the Urgent Community Response team, but to no avail with no further steps being taken at that time, to obtain medical treatment for Victor. Overnight, Victor’s condition did not improve, it being noted that Victor was very poorly. A call was initially made to the GP at 14.53 hours followed by a request for an ambulance at 15.11 hours. On admission to Hospital, the Court heard evidence that Victor had an acute kidney injury and hypernatremia secondary to being grossly dehydrated and malnourished, with Victor having developed osmotic demyelination syndrome, a rare neurological complication of hypernatremia. Attempts were made to treat Victor, however his condition continued to deteriorate and he passed away on the 20th January 2024. 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows:- 1. The evidence highlighted that the only internal investigation that took place in respect of the care provided to Victor was in the context of safeguarding and as a consequence of a request from the Local Authority, under section 42 of the Care Act 2014, following the submission of safeguarding referrals by the Hospital after Victor’s death. 2. Although an internal review of the care arrangements in place for Victor took place alongside the internal investigation, the purpose of this was to identify any further opportunities to strengthen existing procedures, rather than to identify any areas of learning and improvements that could have been made in respect of Victor’s care. 3. The evidence highlighted that there had been little reflection upon the events leading up to Victor’s death, with no facility for the identification of any missed opportunities to provide or obtain care for Victor prior to his final admission to hospital. 4. The evidence highlighted that there was no mechanism for lessons to be learned from deaths which occur during or following admission to the Nursing Home. 6 ACTION SHOULD BE TAKEN 2 In my opinion action should be taken to prevent future deaths and I believe your organisations 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 27th February 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:- The family of Victor William Knowles East Cheshire NHS Trust Henning Hall Nursing Home I have also sent it to the Care Quality Commission 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. 9 DATE: 2nd January 2025 SIGNED:- 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.
Springcare (Macclesfield) Ltd T/A Henning Hall, London Road, T 01260 253555 Sutton, Macclesfield, Cheshire SK11 OLD springcare.org.uk Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths We write in response to the Regulation 28 report which was issued in connection with the Inquest into the death of Victor Knowles, who was a resident of Henning Hall Nursing Home. This letter reflects the response of both Springcare (Macclesfield) Ltd t/a Henning Hall “the Home” and the wider group, Springcare. The Inquest into the death of Victor Knowles was heard at Cheshire Coroner’s Court on 10 to 12 December 2024. Prior to and during the course of the Inquest, the Home provided extensive evidence to assist your inquiry into the care arrangements in place for Victor Knowles whilst a resident at the Home, and the reflection which has taken place following his death to further strengthen the Home’s existing procedures moving forward. We do not seek to repeat this evidence here. A Regulation 28 Report was however issued on 2 January 2025 despite the evidence presented. This raised concerns with regard the processes implemented by the Home to investigate and learn lessons following a resident’s death. It is relevant to explain at the outset that whilst we have reflected very seriously upon the contents of your Report both within the Home and the broader service, we were disappointed that you felt it necessary to issue a Regulation 28 Report in the circumstances. The Home has at all times had in place a comprehensive policy for undertaking internal investigations including guidance on when these are required. As you will appreciate, given the setting in which the Home operates, it would not be reasonably practicable nor proportionate to commence an investigation following all deaths or admissions to hospital. Rather, this requires the review of all incidents whereby a sudden death occurs or any unexpected hospital admission. Furthermore, a monthly review of deaths and hospital admissions considers any themes or trends. This is consistent with the protocols observed by care homes throughout the industry. We are also obliged to notify the Care Quality Commission of deaths in our home without delay under our provider and manager registration. In respect of Victor Knowles specifically, and as explained during the course of the Inquest, he was discharged from hospital and placed at the Home for the purposes of assessment, to Registered Office Address Nicholson House, Shakespeare way, England, SY13 1LJ Company No. 10002403 Springcare (Macclesfield) Ltd T/A Henning Hall, London Road, T 01260 253555 Sutton, Macclesfield, Cheshire SK11 OLD springcare.org.uk identify the correct care pathway for him moving forward. Mr Knowles had been at the Home for only approximately 4 weeks at the time of his re-admission to hospital on 12 January 2024, during which time the Home had sought input from a number of professionals to support Mr Knowles’ fluid and diet needs. Despite the considerable efforts made, Mr Knowles continued to decline and as such the Home arranged for him to be re-admitted to hospital on 12 January 2024 for further medical support. Mr Knowles was discharged from our care and his placement was closed. We learnt that despite medical intervention, Mr Knowles subsequently passed away on 20 January 2024. Following Victor Knowles’ death, a safeguarding report was raised by a member of the hospital dietitian team, reflecting concerns arising from their retrospective review of Mr Knowles’ hospital admission notes. These concerns were carefully reviewed by the safeguarding team in person and remotely, alongside the broader care which Mr Knowles was afforded whilst a resident at the Home. The Home provided its full co-operation with the local authority’s investigation, including through the provision of relevant care records. The safeguarding team subsequently concluded that the safeguarding concerns were unsubstantiated against the Home and “That it would be unrealistic for any care home to be able to resolve Mr Knowles’s long standing health and self-neglect issues.” The review in turn identified broader learnings for the Home, which were immediately implemented. After hearing medical evidence during the course of the Inquest, the Home revisited previous learning from earlier in the year immediately at this point to identify any further lessons to be learnt. Steps were in turn taken to implement any changes in practice, in an effort to further strengthen the systems and procedures already in place, particularly with regard to the admission of pathway for residents under the discharge to assess contract beds and the arrangements for food and fluid monitoring for residents. These steps had been considerably completed prior to the Inquest. This review was in turn further informed following receipt of the Inquest disclosure and the provision of evidence from the attending witnesses. This was not an opportunity which the Home had been afforded (nor could have been) during its initial investigation, given the limits on the information available to it in that evidence was still being collated during the course of the Inquest. Nevertheless, this was fully reflected upon and any additional Registered Office Address Nicholson House, Shakespeare way, England, SY13 1LJ Company No. 10002403 Springcare (Macclesfield) Ltd T/A Henning Hall, London Road, T 01260 253555 Sutton, Macclesfield, Cheshire SK11 OLD springcare.org.uk opportunities for learning identified. Evidence was in turn provided to you in this respect by the attending Home Manager. Accordingly, the Home respectfully submits that the arrangements which it has in place for undertaking investigations, and identifying lessons to be learnt, are appropriate in all the circumstances, and are in line with the processes followed by the wider industry. As such, we have concluded that no further changes are required, over and above those discussed in evidence at the Inquest, to strengthen the existing arrangements in place. Registered Office Address Nicholson House, Shakespeare way, England, SY13 1LJ Company No. 10002403
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