Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0189, written 11 Apr 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Apr 2025 |
|---|---|
| Reference | 2025-0189 |
| Deceased | Patricia Catterall |
| Coroner | John Gittins |
| Coroner area | North Wales (East and Central) |
| Category | Care Home Health related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
John Adrian Gittins Senior Coroner for North Wales (East and Central) 1 2 3 4 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. BCUHB, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd LL57 2PW (“the Health Board”). 2. Pendine Park Care Organisation, Highfield, Summerhill Road, Wrexham LL11 4YE (“the Nursing Home” CORONER I am John Adrian Gittins, Senior Coroner for North Wales (East and Central) 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 the 1st of July 2024 I commenced an investigation into the death of Patricia Ann Catterall (DOB 3.1.43 DOD 23.6.24). The investigation concluded at the end of the inquest on the 11th of April 2024. The cause of death was recorded as being due to 1(a) Hyperosmolar Hyperglycaemic Syndrome (“HHS”) and Sepsis with Pneumonia 2. Frailty of Old Age and Dementia and the conclusion of the inquest was that of a death from natural causes. CIRCUMSTANCES OF THE DEATH On the 11th of June 2024 the deceased’s care was transferred from the Health Board to the Nursing home following the deceased having spent 207 days in the care of the Health Board at Mold Community Hospital Whilst under the care of the Health Board, the deceased’s blood sugar levels were checked three times per day, however once she became resident at Pendine, they were only checked once a day. During the period between the 11th and the 19th of June 2024, the deceased’s condition deteriorated and on the 19th of June she was admitted to the Maelor Hospital Wrexham where she was diagnosed as having HHS and sepsis. Her condition and co-morbidities were such that it would have been inappropriate to aggressively treat these conditions and she passed away a few days later. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed the following matter giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN Tel 01824 708047 | circumstances it is my statutory duty to report to you. The MATTER OF CONCERN is as follows. – That the process of assessment by the Nursing Home prior to the transfer of care to them was not sufficiently robust so as to ensure that all relevant information required for the safe care of a patient had been received and assessed prior to the patient being received into their care. Evidence was received that in the majority of cases (post Covid) there are no face to face assessments prior to patient transfer and that the assessment is therefore dependent on the documentation supplied to the Nursing Home by the Health Board which in some cases may result in not all relevant information being provided. In this instance evidence was given that the Nursing Home did not know that the deceased’s blood sugar levels were monitored three times per days whilst in the care of Health Board. 6 7 8 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 6th of June 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 the Family of the Deceased and to the Chief Coroner. 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 Dated 11th April 2025 Signature Senior Coroner for North Wales (East and Central) Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN Tel 01824 708047 |
2 responses 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.
Dear Mr Gi�ns
Following issue of the Regula�on 28 report please find below ac�ons that have been taken by the
Pendine Park Care Organisa�on.
1. All pre - admission assessments are now being conducted in person except for emergency
admissions.
2. Our pre - admission assessment document has been updated and includes prompts to
ensure all informa�on is requested prior to admission , this includes a sec�on for diabetes , see
atached pre-
admission assessment document .
The informa�on gathered in the pre -admission assessment is then used to formulate the care plan.
Yours Sincerely
Registered Manager Highfield & Nominated Responsible Individual for the Pendine Park Care
Organisation
Pare Pendine d... Pendine Park
Gofa l Goleued ig (fl I Inspiring Care
Pre-Admission Assessment
All residents to be assessed before admission except emergency admissions ta be assessed within 24 hours of admission. For the Assessment,
have the Enquiry Form available, and update any gaps. To be completed by: Clinical Lead Nurse as relevant to conditions and/or Registered
Manager or as authorised by RM. Use this Assessment to create the Care Plan then discontinue within Care Plan. Archive after 12 months.
Name of proposed Resident
Current Location
Date of Pre Admission Assessment
Pre Admission Carried out by
Proposed Date of Adm ission
Proposed Home/ Room No (if known)
Privacy: Please ensure proposed resident/representative is made aware: All information recorded on this document is
processed to decide if we can provide the required services and, if so, prepare for admission accordingly. On admission, this
document will be part of the care and support plan. If services are NOT taken up with Pendine, this information wi ll be
disposed of securely. All Privacy Notices are on our website www.12endine12ark.comL12rivacy.html
Pendine Admission Criteria & Control Check
All must be Yes to approve an Admiss ion Date w ithin next 5 days.
If t ime lapse between date of Pre-Admission Assessment and D Yes
□ No
proposed date of admission is more than 7 days, have you
ensured that the Pre-Admission data is still current and va lid?
If this is an EMERGENCY admission, have you obtained
□ Yes
enough assessment information to make judgement?
□ No
Have you got the DST and all other relevant Third Party Care □ Yes
Plans/Assessments relevant?
□ No
Does the DST identify Category of Care and does t his agree □ Yes
with the proposed admission?
□ No
Residentia l: Have t he District Nurses been given t he DST and
are satisfied that they can provide appropriate care to
support this admission?
D Yes
Is all equipment in place to enable appropriate care to be
delivered from admission onwards?
□ No
D Yes
Have you considered ALL factors and ensured there are no
limiters to the admission?
□ No
Have fees been forma lly agreed with fam ily and/or funding D Yes
authority?
□ No
Are you satisfied that the proposed admission is appropriate □ Yes
and all assessed needs ca n be met?
□ No
Have Resident and fami ly made a definite decision to come
to Pend ine home AND proposed admission is appropriate
with an admission date with in next 5 days?
□ Yes
□ No
D Yes
□ No
If no, ensure relevant information is sought and
gained prior to making decision
If no, ensure relevant information is sought and
gained prior to making decision
If no, do NOT admit until all received
If no, admission may not be possible. Discuss with
re levant parties/RM/NRI.
If no, admission may not be possible. Discuss with
relevant parties/RM/N RI.
If no, do not admit until all relevant equipment in
place.
If no, admission may not be possible. Discuss with
relevant parties/RM/NRI.
If no, admission may not be possible. Discuss with
relevant parties/RM/NRI.
If no, admission may not be possible. Discuss w ith
relevant parties/RM/NRI.
If no, await decision. If yes, bed ca n be held for 5
days. If admission date moves forward, bed may
not be held, w ithout SRl's express agreement and
a (SR l's discretionary) non-refundable fee.
EMERGENCY ADMISSIONS
Care Planning
Equipment
Nursing & Care
Department
Catering Department
Pre-Admission Communication
□ Ensure admitting staff are aware that information within t he Pre-Admission may not be
sufficient and assessments must reflect this
□ Ensure blank Care Plan has been requested including any Advanced Assessments and Care
Plans that wi ll be required (complete and send pages 17 /18 to Ad min)
□ Consider Primary and Named staff- noting Resident preferences & current allocations?
□ Primary Nurse: ....................................................................... ........................... .....................
□ Primary CP: .................. ..................................... ...................... ....................................... .........
□ Named CP: ....... .......................................................................................................................
□ Ensure all equipment required is in place prior to admission
□ Ensure relevant staff updated regarding all physical health, behavioural, personal care and
enrichment needs. DIARY POINT and prepare.
□ Ensure relevant staff are updated regarding any special diets, special aids, allergies etc
□ Complete dietary needs including food levels on Page 17 /18 and send to Ad min
Housekeeping & Laundry □ Ensure relevant staff updated regarding any allergies or special req uests
Administration
Department
□ Ensure relevant staff updated regarding proposed admission date, room number, f unding
issues etc
Maintenance Department
□ Ensure relevant staff updated regarding any special equipment/servicing/room adaptations
required/extra electrical sockets etc
<tJ Pendine Park Care Organisation
Page 1 of 17
ll / 12.05.2025
.
,, .. •,, ·" ', ..
Resident Person.al. Details
,,,,, .. ·'·'
Pre-Admission Assessment
..
.
. <
Known as
Tel No(s)
Marit;il StiltUS
First Language
Next of Ki_n/ Closest Relatiye
Second Contact
Current GI' ..
Care Manager/Social Worker
Full Name
Title
Current
Location
Home
Address
.
Date of Birth
Ethnicity
Contacts
Name
Relationship
Address
Tel No
Mobile
Email
Name
.
Address
Tel No
Email
Will Resident refair1 this GP:ki" I □ Yes □ No
If No, contact local surgeries or,HB to Secure/register GP
Third Party Care Rlans Exist I □ Yes D No
e.g. LA/CHC, physio, SALT, dietician etc If yes, obtain copies
Consultant and l'rofessional..Contacts (Consultants, CPNs, District Nurses, Advocate, IMCA etc)
Name
Role
Contact Details
Funding Source □ LA
□ LHB-CHC □ LHB-Sc117
□ Joint LHB/LA
D Private
Name
Address
Tel No
Email
Continuing Care APP StatUS: l
© Pendine Park Care Organisation
Page 2 of 17
11 / 12.os.2ols
Note: For all physical, behavioural and personal care, record any staff preferences or specific needs
(i.e. gender, height, strength, triggers behaviours etc)
Physical Health
Past and Current History and Physical Health (include relevant dates)
•••••••••••••••••••••••••••·••••·••••••••••••·•••••••••••·•••·••••••••••••••••·•••••••·•••·••·••••••••••••·•••••••••••••····••••••••••••••••••••••••••·•••••••••••••••••··•••••••••••··•·••••••••••••··•••
Resident's understanding of what is happening to them
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11 / 12.05.2025
© Pendine Park Care Organisation
Page 3 of 17
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.......................................................................................................................................................................
.... ---·······································"•"··········
list Current Meds
...................................................................................................................................................................... .
Medication
Explain kept in
Pharmacy where
administered.
Explain policy on
self
administration/ho
mely remedies
······························································-···············································-························································
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.......................................................................................................................................................................
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Resident wish to self-administer? □ Yes D No
Does Resident require Insulin to be administered by Community Nurses? □ Yes □ No
If Yes, has Discharge Team notified Community Team & confirmed they have capacity to action this? □ Yes D No
Covert Administration Plan in Place? □ Yes □ No
If yes inform multi-disc. Ass't is required & will be carried out in due course
If yes, plan available? □ Yes D No
Vaccines - Provide dates of most current
Flu
\
I Covid
I
\ Other I
Pain - State if
Acute or Chronic
and provide
details including
signs of pain and
management
thereof
Allergies -
Food / Drink/
Conditions
e.g., shellfish, hay,
fever, bee stings
etc
Allergies -
Medication
.......................................................................................................................................................................
.......................................................................................................................................................................
.......................................................................................................................................................................
.......................................................................................................................................................................
.......................................................................................................................................................................
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Allergies
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Allergies - Skin .
i.e., washing
powder1 plasters
etc
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© Pen dine Pack Care Ocganisation
Page 4 of 17
11 / 12.0S.20ls
Oxygen Therapy?
Plan if out of normal
ran_ge on discharge
Oxygen Suppliers
Oxygen Therapy
Contact
Nebulisers
Inhalers -
Preventers
Inhalers - Relievers
Smoking Habits/
History
History of Asthma,
COPD, or other
Lung Conditions
□Yes D No I Saturation Levels l
Breathing
% l Normal Range I
%to
%
l How much 02 in place:
I Ema~
]
jTel
litres
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History of Heart
Disease
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Tracheostomy Type
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r:7
Date Last
Chan~ed
I
I
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Ventilation
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Suction Frequency
History of DVT /
Embolism/ Anti
coagulants use or
need
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Suction Machine Required I □ Yes D No
I
If yes, check availability
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•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••·••••••·•••·······························································
•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••·•••··•··••··••··•·····························································
© Pendine Park Care Organisation
Pages of17
11 / 12.os.202s
Di agnosed?
D Yes-Type 1
□ Yes- Type 2
D Yes - Prediabetic
D No - skip sect ion
I
Diabetes
__J
First Diagnosed
History
Blood Glucose
········································•·••··••·••••••••••••••••••••••••••••••••••••••••••••••••••• •••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
·················································•······•·•·········································································•··································
·································•••··••·•··•······••••••••••••••••••••••••••••••••••••••••••••••• •••••••••••••••••••••••••••••••••••••••••••••••• •••••••••••••••••••••
mmols/1
From:
mmols/1 To:
I
Current BM Charts D Viewed in Hospit al/Current Setting
D Copies provided
Risk?
□ Hypo
□ Hyper
On Insulin?
D Yes
D Not seen
0 No
I Ro ute: I
I Dosage
I
Insulin Type
Ant idiabetic meds
Current HbAlc
Test Frequency
Plan if outside
Blood Norm al
Glucose Range on
Discharge
Urinary
Bowel
Continence
Products
%
Target HbAl c
%
Date of last test
······································· ................... ........................... ................................................................ ................. .
····················· .. ·······•····························································•························· .. ···• ........................................... .
..................................................... .... ................................................... ................................ ............. ........... ...
Elimination and Continence
D Fully Continent D Incontinent - type: D Functional D Stress
D Fully Continent D Incont inent - type: D Functional D Constipat ed D Leakage D Urgency
D Overflow D Urge
0 Bladder D Bowels
I Dat e Assessed and
Ref erred fo r Product s
I
..................................................................................... ............................ ... ........................ ...........................
.......................................................................................................................................................................
Prod ucts
................ , ..................................................................................................................................................... .
············· .. ········ ........ ................................. ............... , ....................................... ........................ ....................... .
........................ ............................................................. ........................ ................................ ..........................
Catheterisat ion
D Urinary Catheter
Size and Type
Dat e last changed
D Trial w itho ut Catheter
··················· .. ··········· ........................... ............................... ................................................ ........................... ..
Outcome
....................................... ................................................................................................ .................. ... .... ... ....
........................ , ............................................................................................................................................ ..
··········•·· ........................................................... ... ......................................................... .................................. .
.................................................................................................................................................. ....... ..............
............................... ......................................... .................................................................... ...........................
.......................................... ....................................... .............................................. .......................................
Tel
Email
History of any
Bowel Issues
St om a - Size and
type of bag
Teams Contact
Urology
Bowel
Stoma
© Pendine Park Care Organisation
Page 6 of 17
11 I 12.os.20 s
Nutrition and Hydration
•........................ -·-·· ........................................... ··········································--····································
---
·················-------·-·····································-··-----······································-··--·
····························
·························-············································-·······································--·····································--·
···································-···-········································-----···········································································
•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••·•••·••··••·•• ···························································
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• •••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••··•••·••·•·············································
•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••··••··•·••··········································
••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••·••••·••·•••·••·•••··•••·••·•···················································
Fluid Level
Special diets
incl. diabetic,
vegetarian,
low fat/salt,
supplements etc
Textured diet or
as assessed by
SALT
Food Level
Food Likes
Dislikes/foods to
avoid
•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••·•··••··•••··•······················································
Assistance with
Eating/ Drinking
Required
•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••·············•··················································
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............................................................................................................................................
Special cutlery/
crockery
NG/PEG Feed
Last changed
History of Weight
Loss/Gain and
Current
Management
Weight (Kgs):
History of Eating
Disorders -
Anorexia,
Bulimia, Obesity
etc
••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••·••··••··•····················································
••
••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••···••·••··•··•··························································
□ Bolus
D Flex
Size 1
Type
Feed & rate
per hour
Proposed date of Re-insertion
. .
. ................................................................................................................................................... .
••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••·••··•••·••••·•·········································
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j Height (mJ:l
.
. ......................................................................................................................................................... .
•
·······································································································································•··
•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••·••··•••·•••··················································
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Tel
Email
Teams
Contact
Comm. Dietician
S&L Therapist
PEG Nurse
© Pendine Park Care Organisation
Page 7 of 17
11 / 12.05.2025
Current Maelor Score
Pressure Relieving
Equipment
(check availability)
Skin Condition
(History/ Current)
Tissue Viability and Pressure Care
/ How often repositioned: /
••••••••••••••••••••••••••• .. ······························-··-·······················"''""''"'•·····························-····················"····•""••··
·····----······························································································································-·························
·························································
....................................................................................................... .
--···········································
................................................................................................................... .
.................................................................................................................................................................
.................................................................................................................................................................
.................................................................................................................................................................
Pressure Ulcer{s}?
□ Yes
□ No
/ Moisture Lesion(s)?
/ □ Yes
□ No
Back
If yes, give details
including Grade &
note on Body Map
Dressings used
Vascular Issues with
Legs i.e., Venous leg
ulcers?
lf yes, give details
including management
thereof
Any Malignant
Lesions?
If yes, give details
including management
thereof
Diabetic Foot Care
Regime
□ Yes
□ No
□ Yes
□ No
Teams Contact
Tel
Email
TVN
© Pendine Park Care Organisation
Page 8 of 17
11 / 12.05.202
Safety, Mobility, and Movement
D Independent
D Immobile
D Walks with aids:
D Walks with assistance e.g. 1 or 2 staff
D Frame D Walking Stick
Mobility
Wheelchair Type
Resident's Own
Equipment - list
Moving and Handling - Transfer method & number of persons required
To/from chair
To/from bed
To/from toilet
Hoist type
Bed type
Shower chair
Crash mats
Conditions e.g.
bariatric/MS etc
Sling size
Bedrails/bumpers
Bath support
Other
History of Falls?
□ Yes □ No
Falls, Accidents, or Incidents
If yes, give details
and reasons for falls
{dizziness, activities,
environment,
unknown etc)
Risk Factors i.e.,
osteoporosis,
fractures,
anorexia/bulimia/
excessive exercise/
hormones
Unsteady when standing/walking? l □Yes
□ No
□ Yes □ No l Referrals
made?
□ Yes □ No
Risk Assessment □ Yes D No
available?
If yes, give details
Known to Falls
Team?
Fire Evacuation
Factors
Include smoking,
mobility, capacity etc
© Pendine Park care Organisation
Page 9 of 17
11 / 12.0S.202S
Communication and Sensory Loss - Include how needs ore expressed and any sensory aids
Speech and
Language
Sensory Aids
Sight
Sensory Aids
······························
....................................................................................................................................... .
··················
................................................................................................................................................... .
Hearing
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
Sensory Aids
..............................................................................................................................................................
Reproductive Needs
Last Menstrual
. Period and any
Menstrual Issues
'
.
···················································•··••·••••·••··•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
......................................................................................................................................................................
...................................................................................................................................................... .
Use of Birth
Control/ HRT /
Hormonal Issues
Reproductive
Health History
including Cancer
- Ovarian 7 Breast,
Testicular,
Prostrate etc
Current
Investigations/
Awaiting Results.
···········································································•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
......................................................................................................................................................
........................................................................................................................................................
...............................................................................................................................................
.........................................................................................................................................................
·································································•··••······••··••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
......................................................................................................................................................................
.....................................................................................................................................................
.............................................................................................................................................
'
................................................................................................................................................ ..
......................................................................................................................................................................
·······················"···············
.. ············..........................................................................................
• ••
······················································••····•••·•··••··•··••··•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• '
........................................................................................................................................
. ...
.............................................................................................................................................
.
© Pendine Park Care Organisation
Page 10 of 17
11 / 12.05.20 5
Infection Control
Seizures / TIAs
Neurological Conditions
End of Life/ Palliative Care
Any Infections
e.g. M RSA, C Diff,
TB, Hepatitis, HIV,
Skin Infections,
etc
Conditions
affecting
Consciousness -
History of Vasa
Vagal, Passing
Out, Brain Lesions
or Abnormalities
Huntington's
Disease,
Traumatic and/or
acquired Brain
Injuries,
Strokes etc
End of Life Care
Details
Legal Documents
Advance Directive
living Will
DNACPR
In Place
□ Yes 0 No
□ Yes 0 No
□ Yes 0 No
Copy Available
□ Yes □ No
□ Yes 0 No
□ Yes □ No
Original on Discharge
□ Yes 0 No
□ Yes □ No
□ Yes 0 No
© Pendine Park Care Organisation
Page 11 of 17
11 / 12.05.2025
• ••· Mental Health, Cognition, and Behaviours
Has Mental Capacity been assessed?
If yes, by whom?
I □ Yes □ No
] Date assessed: I
Give outcome
,
Has best interest decision been made? J □ Yes □ No
·································-············
.. -·-···················"''''••·····
···················································································
If yes, give detail~
Any known MHS.Tribunal. Dates? .
J □Yes □ No
If yes, give details
DoLS?
If yes, give details
□ Yes
□ No
Court of Protection --,H&W? .•• □ Yes □ No
Court of Protection - Finance?
Incapacity Order?.
.·.
•·•·
□ Yes □ No
Guardianship?
□ Yes
□ Yes
□ No
□ No
POA
Name
Relationship
Address
Tel No
Mobile
Email
Copy?
Past and
Current
history of any
cognitive
disorders/
conditions/
mental health
· Health & Welfare
Property & Finance
□ Yes □ No
□ Yes □ No
...........................................................................................................................................................................
······················································································································································"·············'"····
...........................................................................................................................................................................
...........................................................................................................................................................................
...........................................................................................................................................................................
...........................................................................................................................................................................
···•················•··•••·······•··•··••··••·••··••·••·•••·••·•·••••••··•••••••••··•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
...........................................................................................................................................................................
...........................................................................................................................................................................
...........................................................................................................................................................................
...........................................................................................................................................................................
...........................................................................................................................................................................
© Pendine Park care Organisation
Page 12 of 17
Cognition
Impression of
cognitive ability
during
assessment
···································································--·························································-···--··································
························-·-------·····································································································································
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To support, you can ask an appropriate question to assess levels of cognition. Ensure question is asked within the genera! flow
of any conversation so as to not be judged as an assessment and they are at ease whilst doing so - see prompts:
Prompts: age, time, home address, current year/location, recognise 2 people, date of birth, well known historical dates, well
known current facts such as name of present Prime Minister/Monarch etc
One to One
Needs and any
Funding
Safeguarding?
.. ••···••··•··•••·••·•••···••·••···•·•······················································
.......................................... .
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......................................................................................................................................................................
□ Yes □ No
......................................................................................................................................................................
If yes, give details
•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••··•••··•·•••·•••··•··•••··•··•••·••·•··········································
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Past Trauma/
History of PTSD
and other
Stress/ Anxiety
Disorders i.e.,
OCD
Vocal or other
Disruptive
Periods likely to
affect Others
·······································••··•··························································································································
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························································••············································································································
......................................................................................................................................................................
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············································································································•·························································
......................................................................................................................................................................
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......................................................................................................................................................................
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Physical or Verbal
Attacks on Others
or Interference
with Other's
Property
••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••··•·•••··•··•••·••·•••·••··••····•··········································
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......................................................................................................................................................................
Ability to Manage
Diet, Hygiene, or
Appearance
••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••·•··••·•••·••••·•···••·•••·••·•••··••·•·················································
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·····································································································································••·······························
••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••·••·•••··•··•••·•••···········································
••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••·••·•••··••·••··•·························································
© Pendine Park Care Organisation
Page 13 of17
11 / 12.05.2025
••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••··••••·•·••••·•··•••··••·••••··•••··•·······························
Compliance to
Participate with
Prescribed Care
(Non Compliance)
Self-Injurious
Behaviour/ False
Allegations /
Suicide Ideation-.
Wandering and
any history of
absconsion
···············································--·--··-···································································--···
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........... ·····················"•"•············································"•"······································································
········································••·····•··••·••····••·••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
·································································•·•·•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
......................................................................................................................................................................
Sexual
Disinhibition
.
. .............................................................................................................................................. .
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Night
Disturbances
......................................................................................................................................................................
....
. ........................................................................................................................................................... .
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Repetitive
Behaviour
·······························································••··••··•··••··••··••··•···••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
......................................................................................................................................................................
Signs and Triggers·
Describe Current
Behaviour
Management -
and how can this
be managed
......................................................................................................................................................................
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Contact
Tel
Email
Teams
CPN
Consultant
© Pendine Park Care Organisation
Page 14 of17
11 / 12.05.20 5
Personal Care Needs and Activities of Daily Living Skills
Record ability to make choices and perform without sup_ervision or assistance
························---------················•·······················-------·································
--··································
Washing Body,
Hands and Face
······--······--·······································-·
·············································--······································-······················
-
·························-----············································-···-········································--···························
Bathing/
Showering
Grooming
(including
shaving, hair,
make up etc)
Dressing/
Undressing
······················-···--···················································································
···························
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......................................................................................................................................................
Oral Health
•••••••••••••••••••••••••••••••••••••••••••••• ••••••••••••••••••••••••••••••••••••••••••••·••··••·•••··•···················································
•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••··•·••••·••·•••·•••··•··•••·······················································
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If yes, please indicate type: D Top D Bottom D Full Set
D Dentures
Dentist required: □ Yes
D No
......................................................................................................................................................................
Foot Care
..
. ..................................................................................................................................... .
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Chiropodist required: □ Yes □ No
Podiatrist required: □ Yes
□ No
Sleeping Pattern
Restlessness
Difficulties
Disorders
(apnoea/walking/
night terrors) and
how to manage
••••
•
•••
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Resting/ Naps
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© Pendine Park Care Organisation
Page 15 of17
11 / 12.05.2025
• Enrichment
If possible, g;ve some details on thef~°Jlowing. Explain full assessment taken during and after admission .
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......................................................................................................................................................................
Their life story so
far
Significant things
about them
(personality,
major
achievements,
etc)
Things important
to them including
dislikes
Hobbies and
interests
Religious Cultural
Spiritual Info
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......................................................................................................................................................................
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Practising
□ Yes D No
© Pendine Park Care Organisation
Page 16 of 17
11 / 12.05.20 5
Any Other Factors/ Additional Information
Family Involvement
/ Support Network
Consultation with
carers/reps/
relatives - how they
would like to
remain involved?
Any other factors
that may influence
the decision to
admit
Any other
comments/
Additional
Information
Name of Assessor:
Signature:
Position:
Date:
© Pendine Park Care Organisation
Page 17 of17
11 / 12.os.202s
Legal Services, Bron Afon, Bryn y Neuadd Hospital, Llanfairfechan LL33 0HH ---------------------------------------------- Gwasanaethau Cyfreithiol, Bron Afon, Ysbyty Bryn y Neuadd, Llanfairfechan LL33 0HH John Gittins HM Senior Coroner North Wales (East and Central) Coroner's Office County Hall Wynnstay Road Ruthin LL15 1YN Ein cyf / Our ref: Eichcyf / Your ref: : Gofynnwch am / Ask for: E-bost / Email: Dyddiad / Date: 04 June 2025 Dear Mr Gittins, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Patricia Ann Catterall I am writing in response to the Regulation 28 Report to Prevent Future Deaths dated 11th April 2025, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching the death of Mrs Patricia Ann Catterall. I would like to begin with offering my deepest condolences to the family and loved ones of Mrs Catterall. In the notice, you highlighted your concern in relation to the level of information provided to care homes during the community hospital discharge and handover process. In response to the notice, our senior nursing team in the East Integrated Health Community have led work to understand the issue across the Health Board. This work has identified that whilst there is a standardised form for discharge plans into care homes, the level of detail is varied. A Task and Finish Group has been set up (consisting of Community Hospital Matrons and Discharge Nurses) to review the current form for suitability, and this work will specifically ensure that frequency of observations and medication is clearly defined within the document. Changes to the form, once finalised and approved, will be shared with the North Wales Care Home Forum, with support from the Quality Development Team (this team supports improvements in quality across commissioned care home services). The new form, and examples to support learning, will be shared with teams and will be included on Team Meeting Safety Briefs. Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd a'r Prif Weithredwr / Correspondence address for Chairman and Chief Executive: Swyddfa'r Gweithredwyr / Executives’ Office Ysbyty Gwynedd, Penrhosgarnedd Bangor, Gwynedd LL57 2PW Gwefan: www.pbc.cymru.nhs.uk / Web: www.bcu.wales.nhs.uk Audit questions will be developed to monitor these changes which will be completed by Ward Managers and Matrons and included in the peer reviews across our services. The audit findings will be included in the monthly Matron Reports into local quality groups for assurance. Our aim is to have this work completed by the end of June 2025. I hope this letter sets out for you the actions we have taken to ensure the concerns raised by yourself are being addressed and mitigated. We would be happy to meet with you and discuss our plans in more detail, or provide further information and assurance should that be helpful. Once again, I offer my deepest condolences to the family and friends of Mrs Catterall for their loss. Yours sincerely Cyfarwyddwr Gweithredol Nyrsio a Bydwreigiaeth / Executive Director of Nursing and Midwifery cc , Deputy Director for Legal Services
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