Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0003, 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 | 2025-0003 |
| Deceased | Peter Good |
| 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 28th June 2024, I opened an inquest into the death of Peter Good who died on 9th January 2024 at Stepping Hill Hospital, Stockport, aged 64 years. The investigation concluded with the inquest which I heard on 17th December 2024. A post mortem examination undertaken by a consultant forensic pathologist on the Home Office Register determined Mr Good died as a consequence of: 1) a) Pneumonia; 1) b) Cerebral infarction, Parkinson’s disease and skin ulceration. At the end of the inquest, I recorded a narrative conclusion to the effect that Mr Good died as a consequence of complications arising from a previous cerebral infarction, Parkinson’s disease and skin ulceration which had significantly deteriorated whilst at the nursing home from which he was admitted to hospital for the final time. CIRCUMSTANCES OF THE DEATH Mr Good was a resident at Hilltop Hall Nursing Home who was nursed in bed as a result of complex care needs particularly arising from a previous cerebral infarction. On 26th December 2023, Mr Good was admitted to Stepping Hill Hospital, Stockport with a blocked gastrostomy tube. On admission, Mr Good was noted to be in poor condition exhibiting what clinical staff perceived as signs of prolonged neglect, leading to a safeguarding alert being raised. Despite treatment with antibiotics, Mr Good deteriorated further whilst in hospital and died on 9th January 2024. 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 court heard evidence that a safeguarding alert was raised by nursing staff at Stepping Hill Hospital shortly after admission on the basis that Mr Good appeared to them very dirty and unkempt with some of his wounds looking and smelling infected. It was further suggested that on admission, Mr Good was noted to exhibit poor oral hygiene, with calculus-covered teeth which the hospital safeguarding nurse regarded as indicative of prolonged neglect. Whilst the Nursing Home’s Deputy Manager gave evidence to the effect that she did not recognise this description of Mr Good, she accepted she had last provided care to him several weeks prior to his admission to hospital. I am concerned in the light of this description that Harbour Healthcare as the owner and operator of Hilltop Hall has not instigated its own investigation into the way which Mr Good was cared for, with a view to considering any ongoing risk of harm to other residents and whether any learning can be derived for staff and managers of the home. 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 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. COPIES and PUBLICATION I have sent a copy of my report to Mr Good’s daughter. I have also sent a copy to the Care Quality Commission, Stockport NHS Foundation Trust, Greater Manchester ICB 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. She 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: 2nd January 2025 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 Mr Peter Mark Good who passed away on 9th January 2024 at Stepping Hill Hospital, Stockport. Background Harbour Healthcare is a family run care provider established in 2012. Hilltop Hall is owned and operated by Harbour Healthcare, it is a nursing home offering nursing care for up to 56 residents with a current occupancy of 26. 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 Mr Good was a resident at Hilltop Hall Nursing Home. He was nursed in bed as a result of complex care needs arising par(cid:415)cularly from a previous cerebral infrac(cid:415)on. On 26th December 2023, Mr Good was admi(cid:425)ed to Stepping Hill Hospital, Stockport with a blocked gastronomy tube. Despite treatment with an(cid:415)bio(cid:415)cs, Mr Good deteriorated further whilst in hospital and died on 9th January 2024. A postmortem examina(cid:415)on determined Mr Good died as a consequence of: a) Pneumonia; b) Cerebral Infarc(cid:415)on, Parkinson’s disease and skin ulcera(cid:415)on Coroners Conclusion At the conclusion of the inquest, the coroner recorded a narra(cid:415)ve conclusion “to the effect that Mr Good died as a consequence of complica(cid:415)ons arising from a previous cerebral infarc(cid:415)on, Parkinson’s disease and skin ulcera(cid:415)on which had significantly deteriorated whilst at the nursing home from which he was admi(cid:425)ed to hospital for the final (cid:415)me.” Coroner's Concerns 1. “The court heard evidence that a safeguarding alert was raised by nursing staff at Stepping Hill Hospital shortly a(cid:332)er admission on the basis that Mr Good appeared to them very dirty and unkempt with some of his wounds looking and smelling infected.” Page 1 of 5 2. “It was further suggested that on admission, Mr Good was noted to exhibit poor oral hygiene, with calculus-covered teeth which the hospital safeguarding nurse regarded as indica(cid:415)ve of prolonged neglect.” 3. “Whilst the Nursing Home’s Deputy Manager gave evidence to the effect that she did not recognise this descrip(cid:415)on of Mr Good, she accepted that she had last provided care to him several weeks prior to the admission to hospital.” 4. “I am concerned in light of this descrip(cid:415)on that Harbour Healthcare as the owner and operator of Hilltop Hall has not ins(cid:415)gated its own inves(cid:415)ga(cid:415)on into the way which Mr Good was cared for, with a view to considering any ongoing risk of harm to other residents and whether any learning can be derived for staff and managers” Response to Concern 1 “The court heard evidence that a safeguarding alert was raised by nursing staff at Stepping Hill Hospital shortly a(cid:332)er admission on the basis that Mr Good appeared to them very dirty and unkempt with some of his wounds looking and smelling infected.” A full inves(cid:415)ga(cid:415)on has been carried out into the Coroner’s concerns. This included taking statements from those present who denied that he le(cid:332) the home appearing dirty and unkempt. Mr Good was admi(cid:425)ed to the home on the 19 October 2023. He was classed as requiring end of life care on admission. He resided at Hilltop Hall for nine weeks and five days. The PCS system records indicate that all care was delivered. He received a bed bath on 23 December 2023 and a shave. On 24 December 2023 he received a wash. On 25 December 2023 he received a wash and a shave. His skin integrity was checked and creams were applied in accordance with his care plan. The records also indicate that regular reposi(cid:415)oning was in place and Mr Good had regular checks by the appointed GP who a(cid:425)ended the ward on a weekly basis. A specialist (cid:415)ssue viability nurse was also involved in his care and the ungradeable pressure ulcers to both of his heels were checked regularly. He had his feet elevated and wore repose pressure boots and used an air flow ma(cid:425)ress with four hourly pressure relief. Feet dressings were changed every day as required. Appropriate no(cid:415)fica(cid:415)ons were made to CQC and the local authority about the ungradeable pressure ulcers. Harbour Healthcare is assured that the procedures regarding assessing, trea(cid:415)ng and monitoring wounds at the home were in place and were being followed. The records confirmed that there were up to date wound charts iden(cid:415)fying all areas affected and the types of wounds affec(cid:415)ng Mr Good who came into the service with these wounds. There was full body mapping in place for each wound. There was a specific care plan in place for new developing blisters and oedema and Mr Good’s treatment of these wounds was monitored by the GP. At the (cid:415)me of the transfer to hospital, Mr Good did have an infected wound and had been visited by the GP in order to provide appropriate treatment. He also had a UTI at the (cid:415)me of admission which was being treated. He was prescribed an(cid:415)bio(cid:415)cs from 20 December 2023. It is likely that this is what the hospital staff are referring to. The paramedics a(cid:425)ending and transferring Mr Good to hospital on 26 December 2023 did not raise concerns about him being dirty and unkempt or about any odour from infected wounds. Page 2 of 5 Ac(cid:415)ons Taken a The records have limited free flow of narra(cid:415)ve by care staff – personalised entries would be more beneficial to provide further descrip(cid:415)on and observa(cid:415)ons. Introduced This informa(cid:415)on has been shared across the company to promote best prac(cid:415)ce and mi(cid:415)gate risk. Introduced via a Harbour Healthcare Bulle(cid:415)n circulated to all Care Home Managers and Regional teams on the 19/2/25 reques(cid:415)ng immediate compliance. This will be monitored by the Regional Opera(cid:415)ons and Care Quality Compliance teams going forward. b The records confirm that the range of care needs required by Mr Good were in place. There were already systems in place to monitor pressure care and the general presenta(cid:415)on of service users. The management teal m held weekly ward rounds with the GP and carried out clinical risk mee(cid:415)ngs. There was evidence of appropriate referrals to other professionals when required. What is not clear from the records is the general condi(cid:415)on of Mr Good and his appearance/ presenta(cid:415)on, this must be introduced to ensure a more personalised view of the resident is in place. Introduced. This informa(cid:415)on has been shared across the company to promote best prac(cid:415)ce and mi(cid:415)gate risk. Introduced via a Harbour Healthcare Bulle(cid:415)n circulated to all Care Home Managers and Regional teams on the 19/2/25 reques(cid:415)ng immediate compliance This will be monitored by the Regional Opera(cid:415)ons and Care Quality c Compliance teams going forward. The Hospital transfer documenta(cid:415)on must be completed on the hospital transfer document on PCS and copied to the resident file on every resident’s admission to hospital with all areas of the hospital transfer sheet completed, including a full body map. A verbal handover to paramedics is insufficient. This informa(cid:415)on has been shared across the company to promote best prac(cid:415)ce and mi(cid:415)gate risk. Introduced via a Harbour Healthcare Bulle(cid:415)n circulated to all Care Home Managers and Regional teams on the 19/2/25 reques(cid:415)ng immediate compliance. This will be monitored by the Regional Opera(cid:415)ons and Care Quality teams going forward. Response to Concern 2 “It was further suggested that on admission, Mr Good was noted to exhibit poor oral hygiene, with calculus-covered teeth which the hospital safeguarding nurse regarded as indica(cid:415)ve of prolonged neglect.” A full inves(cid:415)ga(cid:415)on has now been conducted. The inves(cid:415)ga(cid:415)on found that the records confirm that oral hygiene needs were carried out every day. It is noted that mouth care was being carried out during the early hours of the morning and the staff explained this as being due to Mr Good’s saliva(cid:415)on and the need to protect his facial skin and his neck in order to make him comfortable. It is unclear whether the calculus to Mr Good’s teeth was present before admission to Hilltop Hall on 19 October 2023. If it was, oral hygiene and brushing would not have removed the calculus. Mr Good was receiving end of life care from admission and given his presen(cid:415)ng physical condi(cid:415)on there were no arrangements in place for dental appointments. Page 3 of 5 We apologise that there was no oral hygiene care plan in place. An assessment was completed and the informa(cid:415)on was recorded on the End of Life care plan instead. Ac(cid:415)ons Taken a) There was no oral hygiene care plan - the oral hygiene care assessment was completed but this was not linked to a full care plan. This is recorded on the End-of-life care plan; however, a full oral hygiene care plan should have been in place. This informa(cid:415)on has been shared across the company to promote best prac(cid:415)ce and mi(cid:415)gate risk. Introduced via a Harbour Healthcare Bulle(cid:415)n circulated to all Care Home Managers and Regional teams on the 19/2/25 reques(cid:415)ng immediate compliance. This will be monitored by the Regional Opera(cid:415)ons and Care Quality Compliance teams going forward Response to Concern 3 “Whilst the Nursing Home’s Deputy Manager gave evidence to the effect that she did not recognise this descrip(cid:415)on of Mr Good, she accepted that she had last provided care to him several weeks prior to the admission to hospital.” We apologise that a member of the senior management team was not present at this inquest to support the deputy manager’s evidence. We also apologise that a full root cause inves(cid:415)ga(cid:415)on had not been carried out prior to the inquest to enable us to respond from an informed posi(cid:415)on. Ac(cid:415)ons Taken a) A member of the Senior management must and will a(cid:425)end and support our team members at all Coroner court hearings – This informa(cid:415)on has been shared across the company to raise awareness, promote best prac(cid:415)ce and mi(cid:415)gate risk. This informa(cid:415)on has been shared via a Bulle(cid:415)n to all home management teams, regional support teams and the Senior leaders for informa(cid:415)on b) Harbour Healthcare will in future always consider legal representa(cid:415)on at Coroners court c) moving forward to ensure our team member are appropriately supported and represented. In all deaths that are referred to the coroner, Harbour Healthcare will complete a root course analysis, a full inves(cid:415)ga(cid:415)on and complete a candid lessons learnt. This informa(cid:415)on has been shared across the company to promote best prac(cid:415)ce and mi(cid:415)gate risk. This informa(cid:415)on has been shared via a Bulle(cid:415)n to all home management teams, regional support teams and the Senior leadership team on the 19/2/25. This will be monitored by the Director of Strategic Risk, Safeguarding & Regula(cid:415)on. Response to Concern 4 “I am concerned in light of this descrip(cid:415)on that Harbour Healthcare as the owner and operator of Hilltop Hall has not ins(cid:415)gated its own inves(cid:415)ga(cid:415)on into the way which Mr Good was cared for, with a Page 4 of 5 view to considering any ongoing risk of harm to other residents and whether any learning can be derived for staff and managers” We apologise sincerely for not conduc(cid:415)ng a full inves(cid:415)ga(cid:415)on prior to the inquest. As Mr Good died in hospital, it would not be our usual prac(cid:415)ce to conduct an internal inves(cid:415)ga(cid:415)on unless there was reason to. We were not no(cid:415)fied of the safeguarding referral un(cid:415)l the Inquest. Furthermore, he was receiving End of Life care and his death was expected. This has now been conducted and we have taken steps to ensure that it will not happen again. Ac(cid:415)ons a) In all deaths that are referred to the coroner, Harbour Healthcare will complete a root course analysis, a full inves(cid:415)ga(cid:415)on and complete a candid lessons learnt. This informa(cid:415)on has been shared across the company to promote best prac(cid:415)ce and mi(cid:415)gate risk. This informa(cid:415)on has been shared via a Bulle(cid:415)n to all home management teams, regional support teams and the Senior leadership team on the 19/2/25. This will be monitored by the Director of Strategic Risk, Safeguarding & Regula(cid:415)on. b) To ensure lessons are being learned more widely the Reg 28 No(cid:415)ce and responses have been shared across Harbour Healthcare Care Homes with a view to ensuring each of our homes benchmark themselves against the ac(cid:415)ons iden(cid:415)fied and that Regional Opera(cid:415)ons and Care Quality compliance teams monitor these to ensure compliance and evidence of lessons learned. This informa(cid:415)on has been shared across the company to promote best prac(cid:415)ce and mi(cid:415)gate risk. Introduced via a Harbour Healthcare Bulle(cid:415)n circulated to all Care Home Managers and Regional teams on the 19/2/25 reques(cid:415)ng immediate compliance. This will be monitored by the Director of Strategic Risk, Safeguarding and Regula(cid:415)on. Conclusion We would like to take this opportunity to offer our sincere condolences to the family of Mr Good on his passing. We apologise sincerely for our failure to conduct a robust inves(cid:415)ga(cid:415)on prior to the Inquest. Had this happened we would have been in a posi(cid:415)on to respond appropriately during the Inquest and provide the necessary records and informa(cid:415)on to the Coroner. Ac(cid:415)on has been taken to ensure that this does not happen again. We believe the above response addresses all the points highlighted by the Coroner through the Regula(cid:415)on 28 report. Our inves(cid:415)ga(cid:415)ons have led to relevant improvements being made to our processes to ensure our service users are protected from the poten(cid:415)al risk of harm and that we are more ac(cid:415)vely involved in Coronial proceedings moving forwards to aid the inves(cid:415)ga(cid:415)on process. Should the Coroner require any further informa(cid:415)on about the inves(cid:415)ga(cid:415)on that has taken place, including suppor(cid:415)ng evidence, please do not hesitate to contact us. Page 5 of 5
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