Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0020, written 13 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 | 13 Jan 2025 |
|---|---|
| Reference | 2025-0020 |
| Deceased | Diane Poole |
| Coroner | Andre Rebello |
| Coroner area | Liverpool and Wirral |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Victoria Residential Home, Victoria House 1 CORONER I am Andre REBELLO, Senior Coroner for the coroner area of Liverpool and Wirral 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 26 September 2024 I commenced an investigation into the death of Diane POOLE aged 83. The investigation concluded at the end of the inquest on 13 January 2025. The conclusion of the inquest was that: Diane Poole died from an Accidental death Official 4 CIRCUMSTANCES OF THE DEATH On the 31st August 2024 Diane Poole along with another resident left Victoria House Care Home through a faulty emergency escape door. The door was defective and the alarm did not sound. Staff in the residential home were unaware that Diane Poole was missing for three hours. Diane Poole was found following an unwitnessed fall on Steel Street, Wallasey. She was taken to the trauma centre at Aintree University Hospital where she was treated for head and facial fractures. She was discharged from Aintree University Hospital on the 17th September 2024 to Acorn House Residential Home. She died on 23rd September 2024. It is found that the fall and injuries more than minimally contributed to her death. It is unclear as to whether the fall would have occurred had she been noticed as missing earlier. 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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: (brief summary of matters of concern) The Court received evidence of the following: The investigation uncovered both the fault of the emergency exit door and a lack of awareness among the staff, highlighting the need for immediate corrective measures to prevent a recurrence of this incident. To address these issues, several actions will be implemented. Immediate corrective actions have been implemented to prevent a recurrence of this incident. Actions include: l they are functioning correctly. l Rigorous Alarm Checks: Regular inspections of all emergency exit alarms to ensure Increased Resident Headcounts: Staff will conduct hourly headcounts of all Regulation 28 – After Inquest Document Template Updated 30/07/2021 Engaging Activities for High-Risk Residents: Structured, stimulating activities will be residents, with half-hour checks for those deemed high-risk. l introduced to engage high-risk residents and reduce behaviours that may lead to attempts to leave the facility. l focused, ensuring clear communication and continuity of care. l importance of supervision, resident safety, and emergency procedures. Ongoing Staff Training: Regular training sessions will be conducted to reinforce the Improved Shift Handover Procedures: Shift handovers will be more resident- The Court seeks clarification that these actions have been implemented and are continuing 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 March 10, 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 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Official I have also sent it to CQC Care Quality Commission, City Gate Gallowgate Newcastle upon Tyne Tyne and Wear NE1 4PA who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. They may send a copy of this report to any person who they 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 Dated: 13/01/2025 Regulation 28 – After Inquest Document Template Updated 30/07/2021 Andre REBELLO Senior Coroner for Liverpool and Wirral Official Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Provider CQC Overall rating Requires Victoria House (Wallasey) Ltd Date of inspection Service/Establishment Victoria House 20.01.25 13.01.25 Improvement Nominated Individual Registered Manager to 22.01.25 22.01.25 until Date action plan created Contact from 23.01.25 Background Information Coroner’s Report dated 13.01.25 in to the death of resident Diane Poole Deceased. Diane left the Home with another resident on 31.08.24 through a conservatory push bar exit which was alarmed, however the alarm failed to activate on opening. Staff were unaware that the residents were missing for three hours. Diane Pool was found following an unwitnessed fall on Steel Avenue, Wallasey. She was taken to the trauma centre at Aintree University Hospital where she was treated for head and facial fractures. She was discharged from Aintree University Hospital on the 17.09.24 to Acorn Residential Home. She died on 23.09.24. Coroner concluded that Diane Pool died from an accidental death and that the fall and injuries sustained more than minimally contributed to her death. It was unclear as to whether the fall would have occurred had she been noticed as missing earlier. This action plan is to identify improvements required, monitor progress of the improvements, and ensure the regulatory compliance is achieved at the service. The action plan focusses on the initial assessments identified in the Homes Investigation Outcome of 15.10.24. The action plan will be developed as progress is made and any further areas for improvement identified will be added to this overarching action plan. KEY Green – Completed Amber – Started/Ongoing Red – Not yet started. Area for improvement identified Rigorous Alarm Checks Increased Resident “Headcounts” Engaging Activities for High-Risk Residents Improved Shift Handover Procedures Ongoing Staff Training Who is responsible for the Action Aim completio n Date Date completed Updates Action to be taken. Detail that includes measurable action Regular inspections of all emergency exit alarms to ensure they are functioning correctly. Staff will conduct hourly “headcounts” of all residents, with half hour checks for those deemed high risk Team Leader at the start of each shift PLUS management daily Team Leaders Structured, stimulating activities to engage high-risk residents and reduce behaviours that may lead to attempts to leave the Home Shift handovers will be more resident focussed, ensuring clean communication and continuity of care. Activities co- ordinator with input from Management Team Leaders and Management Already completed Already Completed Completed 07/02/2025 Introduced following the incident and ongoing daily. Now signed for by seniors and handyman daily. Signatures are for checks at 08:00hrs and 20:00 hrs, specifically when shifts are changing. Introduced immediately following the incident and ongoing daily. The activities co-ordinator is now in place for 5 afternoons per week to engage with residents in daily activities. Already completed Introduction of senior what’s app group that is shared with all seniors and management at the end of every shift Regular training to reinforce the importance of supervision, resident safety and emergency procedures Management March 25 Staff re-enrolled on Safeguarding training along with Nutrition and Hydration (as it was found that staff did not notice that residents were missing during morning drinks round). Staff also enrolled on DOLS course and a further general role centred course covering the importance of Communication, Reporting and Recording, Daily Tasks and Team Working. 2 Improved shift paperwork Closure of the front lounge area where the escape door is situated Environment Restructuring New paperwork to evidence that all residents receive morning and afternoon refreshments Healthcare Assistants Area closed off following the incident Management Areas to the front of the Home are being restructured to prevent possible future incidents Providers Conservatory door Door to be made permanently inaccessible Management/ Providers Completed Staff complete nutrition forms. 31.08.24 14/02/20 25 The lounge area was immediately closed off and is now closed to residents (now being used a meeting room – family room). Work has been completed on securing the outside front door to the premises. By electronic fob and self- closer. This now gives a further layer of protection against the possibility of residents on Dol’s leaving the premises. The area leading to the foyer also has restricted access via a fob system. 22.01.25 Conservatory door made permanently inaccessible by way of change to hinges and removal of opening mechanism and hand le. Note: this is not a fire door, the fire door is situated a few feet away 3
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