Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2025-0090, written 12 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 | 12 Dec 2024 |
|---|---|
| Reference | 2025-0090 |
| Deceased | Jean Mullen |
| Coroner | Nicola Mundy |
| Coroner area | South Yorkshire (East) |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
CORONER'S COURT AND OFFICE - pel seal CROWN COURT 194 COLLEGE ROAD SOUTH YORKSHIRE (East District) DONCASTER DN1 3HS. email: Tel: (01302) 737135 a Fax: (01302) 736365 Date: 12 December 2024 Case: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: EE, Chief Executive, City of Doncaster Council 1. CORONER lam Ms N J Mundy for South Yorkshire East 2. CORONER’S LEGAL POWERS | 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 htto://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3. INVESTIGATION and INQUEST On 5 July 2024 | commenced an investigation into the death of Jean MULLEN. The investigation concluded at the end of the inquest . The conclusion of the inquest was Accidental death. ja Fracture of neck and subdural haemorrhage 1b Fall from height 4, CIRCUMSTANCES OF THE DEATH This case relates to the unexpected death of an 87 year old woman who was found collapsed at her home address. The death has been referred by South Yorkshire Police, who have confirmed that there are no suspicious circumstances. According to the referral, Mrs Mullen's pendant alarm triggered at 03:21hrs on the 22nd June 2024. it is noted that the alarm company heard Mrs Mullen scream at 03:31hrs. She was last heard speaking at 03:38hrs. The alarm responders attended at the address but they were unable to gain access. Paramedics attended and forced entry. Mrs Mullen was found faced down at the bottom of the stairs. The police have described her as having her bottom in the air, in a foetal like position and noted a small cut on the upper left side of the scalp and a visible fracture to the left forearm. According to the referral, the attending Paramedics commenced full ALS, but they were unable to save Mrs Mullen. HE advised that in March 2024, her Mother suffered a fall at home, which resulted in her being admitted to Doncaster Royal Infirmary. [EEE confirmed that her Mother sustained some bruising, but no significant injuries. [J informed me that she lives in Shropshire, so she is not able to directly support her Mother. [EE advised that following her Mother's fall, in March, she travelled to Doncaster. [EEE advised that she visited her Mother's address and noted that her Mother was not coping very well. The property was untidy, with food left out. At this point, EE realised that her Mother needed more support. HEB advised that whilst in Hospital, her Mother underwent a needs assessment via the local authority. An occupational therapist also assessed her Mother. IMadvised that her Mather was discharged from Hospital on the 22nd March 2024 with a care package in place. MA advised that 1 x Carer would attend in a morning and 1 x Carer at night to assist her mother. advised that this was to assist with getting up, going to bed and showering. I advised that her Mother was a strong willed woman and she would not always accept help. IB advised that her Mother would also do things that she wasn't supposed to, such as coming downstairs on her own. | advised that her Mother's bedroom and bathroom were upstairs, but she would use a commode downstairs during the day. HB advised that she thought that the stairs were becoming too much for her mother, which she had communicated to social care, but J was advised that her Mother had completed a stairs assessment which she had passed. HEM advised that she thought her Mother should have been placed into a care home, but the Local Authority advised that her Mother was not yet ready for this. | have spoken with Doncaster Royal Infirmary, who have provided a copy of the discharge letter relating to the last admission - see attached. According to the letter, Mrs Mullen was admitted to Doncaster Royal Infirmary on the 20th March 2024 following a fall from bed and long lie. The letter notes that Mrs Mullen was managed with IV fluids for raised CK levels. X rays confirmed no acute injuries, but there was evidence of long standing osteoarthritis changes. The urine culture was negative. No postural hypotension was noted - ECG Sinus rhythm. The letter confirms that Mrs Mullen was discharged on the 22nd March 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 will occur unless action is taken. In the circumsiances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — During the course of the inquest | heard evidence regarding communications between various departments of Adult Social Care and Home First and in particular STEPS. There had been an assessment by the therapist at Doncaster Royal Infirmary regarding Mrs Mullen returning to a safe home environment and what support and equipment would be required to allow that to take place. This included an assessment in the home with social workers present. A care package was provided by STEPS and it quickly became apparent that long term care and support would be required in the home and thus an application was completed on the 12th April. Mrs Mullen's family referred to them being informed that a grab rail would be required at the top of the stairs near the bathroom to help Mrs Mullen navigate to the bathroom thus reducing the risk of falls. This was not provided. A fall occurred when Mrs Mullen was in the shower but the carers failed to escalate this and made no referrals for any further assessment to take place in relation to Mrs Mullen's mobility and ability to continue living safely at her home address. Further this was a missed opportunity to assess whether any other aids or equipment were needed to support her. Had this taken place it is likely that the absence of the grab rail would have been identified. This was a further missed opportunity. Finally, the care and support placement referred to in the second exhibit to E's report made no reference to the issue of stairs and the risk of falling that they presented. In order to reduce the risk of such a situation occurring in the future | invite you to consider the following: (1) The training of staff regarding the importance of recording instances such as falls and escalating same. (2) Following up on recommendations for aids and equipment required to ensure a safe home environment for elderly persons such as Mrs Mullen. (3) The importance of full and accurate record keeping. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you I 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 the 6th February 2025. |, 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 | have sent_a copy of my report to the Chief Coroner and to the following Interested Persons as | have also sent it to Doncaster Royal Infirmary who may find it useful or of interest. | 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. 12 December 2024 9. Signature w— Ms N J Mundy LL.B (hons) Senior Coroner for South Yorkshire East
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.
www.doncaster.gov.uk Ms N J Mundy The Coroner for South Yorkshire (East District) Coroner’s Court and Office Crown Court College Road DONCASTER DN1 3HS Email Dear Ms Mundy, Contact: Our ref: Your ref: Telephone: Email: Date: 5th February 2025 IN THE MATTER OF A REGULATION 28 REPORT TO PREVENT FUTURE DEATHS FOLLOWING AN INQUEST INTO THE DEATH OF JEAN MIULLEN This response is provided to address the concerns raised by your Regulation 28 report dated 12 December 2024 in which you invite me, on behalf of City of Doncaster Council (“the Council”), to consider the following: (1) The training of staff regarding the importance of recording instances such as falls and escalating the same. (2) Following up on recommendations for aids and equipment required to ensure a safe home environment for elderly persons such as Mrs Mullen. (3) The importance of full and accurate record keeping. I have been able to consider the aforesaid points with reference to the heads of the relevant services and am able to provide the following information by way of reassurance that the Council’s systems of record keeping and communication are robust and effective: (1) The training of staff regarding the importance of recording instances such as falls and escalating the same: ➢ All of our social care staff undergo specific training as a matter of course on the need for detailed accurate records to be maintained in care settings, including the recording of slips and falls and general health related events. ➢ As a matter of practice, we use the Mosaic electronic recording system to facilitate our record keeping and all social care staff are fully trained and familiar with the processes involved. Pre-populated forms are available for various tasks, including reports, risk assessments and interactions that need Office of the Chief Executive, City of Doncaster Council, Civic Office, Waterdale, Doncaster, DN1 3BU to be recorded and this has the advantage of directing staff to the questions and issues that need to be addressed. ➢ By way of reinforcing this and other aspects of training, front facing social care staff are required to attend one to one supervision sessions on a monthly basis. The purpose of these sessions is to discuss ongoing cases which are specific to that member of staff and to provide the opportunity to raise any issues of concern. ➢ The discussion of matters of concern is not limited to the monthly sessions and social care workers are constantly engaging with each other and sharing experiences and knowledge to solve any problems arising. ➢ The need for detailed accurate records to be maintained in care settings is stamped into the DNA of our social care staff, as well as being a key requirement of CQC, whose jurisdiction we are subject to as care providers. We are well aware of our reporting and recording obligations and are fully compliant with these standards and requirements. ➢ In addition to the measures above, we undertake internal audits on a regular basis to ensure consistency in reporting. Cases are selected on a random basis at the rate of two cases per team per month and the records are scrutinised for discrepancies and any failures to follow up concerns and/or recommendations for referrals etc. ➢ Care packages are provided by independent care providers who are not associated with the Council, but who are subject to regulation by CQC and who are engaged pursuant to contracts that stipulate the care standards to be expected. They are also required to adhere to the same protocol as the Council in respect of record keeping. ➢ The records produced by care providers are subject to internal audits by the Council’s commissioning department on a regular basis in the same way that the Council’s own records are subject to scrutiny. ➢ The care providers also have their own internal auditing processes and would face significant commercial disadvantage if they failed to adhere to the standards expected. In such event they might lose the benefit of any contracts or more significantly, might be held responsible for any safeguarding issues arising, which had not been properly addressed. ➢ It should be noted that carers and social care staff are not qualified to diagnose medical conditions or to make recommendations for aids and equipment. Their role is to raise any perceived concerns and to direct the person in question to the relevant professional for advice, usually an occupational therapist, physiotherapist, or District Nurse. All staff are aware of this process and do not require permission to take such steps. (2) Following up on recommendations for aids and equipment required to ensure a safe home environment for elderly persons such as Mrs Mullen: where a recommendation has been made for aids and equipment, this will be ordered by the professional making the recommendation. The Council will always follow up any delay in provision and assist in any way possible. Office of the Chief Executive, City of Doncaster Council, Civic Office, Waterdale, Doncaster, DN1 3BU Since this incident and as part of “lessons learnt” we have set up a “Home First Forum” with a view to providing all domiciliary home care providers information as to when and to whom they should direct any referrals. The first event was held on 30 January 2025 and further events will be held on a quarterly basis. (3) The importance of full and accurate record keeping: the Council is well aware of the importance of full and accurate record keeping and has robust systems in place to ensure that this is maintained, as set out above. I consider that it might be useful to make some further points to put Mrs Mullen’s situation into context and to address some of your observations made in respect of the events leading up to her fall. I understand that Mrs Mullen was admitted to hospital for several days after a fall from her bed (in the context of suffering with a urinary tract infection) and was discharged home on 22 March 2024. Whilst she was in hospital, a needs assessment was carried out by the Council’s STEPS team. This team provides reablement to persons from hospital to home and if care is required, this will be provided by the Council free of charge for 6 weeks. The STEPS team concluded that Mrs Mullen needed assistance to manage at home and a care package was set up with carers visiting twice a day in the morning and evening. At the same time an assessment was carried out by the NHS occupational therapist, Beverley Hanes, who passed her fit to manage on stairs. Beverley Hanes also visited Mrs Mullen’s home the day before the discharge date and maintained her advice in respect of the stairs. This decision was not within the expertise of the Council’s social care staff but lay within the expertise of the occupational therapist. Mrs Mullen did not return home until various remedial measures had been taken by her daughter (the owner of her home) including a general clean up and securing pieces of loose carpet. Mrs Mullen then received reablement care for 6 weeks and no concerns were raised during this period about her ability to manage at home. At the 6 week point a review was undertaken by the Council ( ). It is correct that she did not undertake a stairs assessment. Mrs Mullen had been passed fit to manage on stairs by the occupational therapist and a further assessment was not considered to be necessary. It would not have been within ’s remit to undertake such an assessment in any event. If there had been any concerns about Mrs Mullen’s ability to manage stairs, this would have been referred back to Beverly Hanes for further assessment. Following this review, Mrs Mullen’s daily care package continued, with additional care being provided on top 3 days per week to assist her with showering. The care provider was Newdon Care. The Council does not have any record of Patricia Mullen informing social care that the stairs were becoming too much for her mother and neither was this identified as an issue by the carers. If any concerns had been expressed by Patricia Mullen, the carers or Mrs Mullen herself (who had full capacity), this would have been recorded and investigated. Mrs Mullen also had daily contact with a neighbour with whom she had a close relationship. The neighbour spent most of each day with Mrs Mullen at her home and was present at the NHS home assessment prior to Mrs Mullen’s discharge from hospital. The neighbour did not express any concerns either to social care about any deterioration in her condition. Office of the Chief Executive, City of Doncaster Council, Civic Office, Waterdale, Doncaster, DN1 3BU The reference to the grab rail appears in the Ambulance records and is attributable to the paramedics who attended upon Mrs Mullen after her fall. This suggestion was not taken up by the occupational therapist and would not therefore have been followed up by social care. Following the Inquest, we have made further enquiries and have established that the reference to the fall in the shower relates to an isolated event that was in fact documented by Newdon Care. I understand that this party was not required to give evidence at the Inquest and therefore this documentation was not available to the Inquest. As a matter of practice, a single fall event would not be expected to raise a referral. Mrs Mullen was in receipt of care specifically to assist her with showering and any concerns in this respect would have been referred by the carers from Newdon Care to RDaSH for the falls service, occupational therapy, and physiotherapy, in the event that they considered this to be in Mrs Mullen’s best interests. Learning from the incident: we strive as an organisation to improve our practices wherever we can and have reflected at length on the sad outcome for Mrs Mullen. In terms of action to be taken, we will continue to provide training to our staff and will continue to reinforce the need for accurate record keeping, particularly in relation to instances such as falls. We will also reinforce the need for carers and social care staff to escalate any concerns by making appropriate referrals to professionals who will be able to assess the risk and recommend further measures that might need to be put into place to address such risk. This will be further facilitated by the establishment of the “Home First Forum”. Please let me know if I can be of any further assistance. Yours sincerely Chief Executive City of Doncaster Council Office of the Chief Executive, City of Doncaster Council, Civic Office, Waterdale, Doncaster, DN1 3BU
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