Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2025-0405, written 6 Aug 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Aug 2024 |
|---|---|
| Reference | 2025-0405 |
| Deceased | Alfred Sparrow |
| Coroner | David Reid |
| Coroner area | Worcestershire |
| 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: , Chief Executive Officer, Cardinal Healthcare, Image Court, 328-334 Molesey Road, Walton-on-Thames, Surrey KT12 3LT. 1 CORONER I am David Donald William REID, HM Senior Coroner for Worcestershire. 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 12 December 2023 I commenced an investigation and opened an inquest into the death of Alfred Edward SPARROW. The investigation concluded at the end of the inquest on 6 August 2024. The conclusion of the inquest was that Mr. Sparrow “died from natural causes.” 4 CIRCUMSTANCES OF THE DEATH In answer to the questions “when, where and how did Mr. Sparrow come by his death?”, I recorded as follows: “On 11.9.23 Alfred Sparrow, who lived with vascular dementia, became a resident at The Meadows Nursing Home, Catshill, Bromsgrove. During his time there, his oral intake of food and fluids would fluctuate, and he gradually became more frail. At the end of November 2023 his condition deteriorated significantly, and he declined and died there on the evening of 1.12.23.” 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 circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – 1) Mr. Sparrow had a longstanding diagnosis of vascular dementia, and his care plan stated that he required full assistance and support from staff at mealtimes with regard to his intake of food and fluids, and that he would not support himself if food and drink was placed in front of him. Despite the care plan, entries in Mr. Sparrow’s care notes, while recording his food and fluid intake, made no mention of whether a staff member at The Meadows Nursing Home was assisting him in this regard. Having heard evidence at the inquest, I was satisfied, and found as a matter of fact, that staff at The Meadows Nursing Home did not always assist Mr. Sparrow with his food and fluid intake; 2) Furthermore, an entry in Mr. Sparrow’s notes purports to show that he was given, and drank 200ml of tea at 2030hrs on 1.12.23, some two 1 hours after he had died. That entry was clearly false, and gave rise to a concern that staff might have been completing care note entries which did not reflect their actions in relation to Mr. Sparrow. If that is the case, then there is a clear concern that residents’ lives will continue to be put at risk by such actions; 3) The manager of The Meadows Nursing Home, , gave evidence at the inquest that, at the request of the Care Quality Commission, she carried out an investigation into the events surrounding Mr. Sparrow’s death, and that she did so by looking at his care plan and care notes, and by speaking to staff who knew him. In her investigation, she failed to spot the false entry of 1.12.23 referred to above. Had she done so, her investigation would have identified at an early stage the deficiencies identified at 1) and 2) above. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you, as the Chief Executive Officer of Cardinal Healthcare, which runs The Meadows Nursing Home, 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 1 October 2024. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following: (a) and , Mr. Sparrow’s daughters. 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 6 August 2024 David REID HM Senior Coroner for Worcestershire 2 3
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Cardinal "SLL Healthcare Cardinal Healthcare Image Court 328-334 Molesey Road Walton-On-Thames, Surrey, KT12 3LT Tele: 01932 253403 26.09.24 Mr David Reed HM Senior Coronerfor Worcestershire Response to Regulation 28 Prevention of Future Deaths Report Regarding the Death of Mr. Alfred Edward Sparrow Cardinal Healthcare - The Meadows Nursing Home We are writing in response to the Regulation 28 Prevention of Future Deaths report issued fol- lowing the Inquest into Mr Sparrow's death. We take the coroner's concerns very seriously and have conducted a thorough review of our practices and processes. Below, we address each con- cern in detail, outline the actions taken, and propose future improvements, all Informed by re- flective practice and lessons learned from this case. 1. Concern Regarding Mealtime Assistance The coroner's first concern revolves around the care provided to Mr Sparrow during mealtimes. His care plan at his previous care home specified that he required full assistance with food and fluid intake due to his diagnosis of vascular dementia. However, care notes documenting his food and fluid intake did not clearly indicate whether he was being assisted, raising concerns that Mr Sparrow might not always have received the assistance required, potentially putting his health at risk. Our thoughts on the Issue His care plan was assessed when Mr Sparrow was admitted to The Meadows Nursing Home on 11 September 2023. We concluded that, while he had a diagnosis of vascular dementia and his previous home had récorded that he required full assistance with eating, he still demonstrated some ability to feed himself. Encouraging independence was essential to maintaining Mr Spar- row’s dignity and preventing deskilling, which his daughter confirmed in her statement: “My fa- ther was moved into The Meadows Care Home on the 11th of September 2023. He was alert and able to feed and drink unassisted.” However, we acknowledge that while our intentions were to respect his dignity and foster inde- pendence, our documentation needed to reflect this nuanced ‘approach fully, The failure to ex- pilcitly record whether staff assisted Mr Sparrow during meals created uncertainty, This omission highlights where we must improve our practices to:‘ensure transparency and clarity in care rec- ords. Actions Taken and Future Improvements Care Plan'and Documentation Review: A full review of all resident care plans is underway to en- sure they accurately reflect each resident's needs and any changes in their condition. In Mr Spar- row’s case, we now realise that his ability to feed himself may have fluctuated, and such fluctua- tions should be recorded better in care notes, Training in Person-Centered Documentation: All staff receive additional training to improve their documentation of the level of assistance provided during meals. It is critical that staff not only record food and fluid intake but also specify the level of support provided to the resident, whether full assistance or encouragement. implementation of Care Vision: We are in the final stages of contracting a new care planning sys- tem, Care Vision, which we hope will be fully operational by January 2025, Care Vision will prompt staff in real time to record food and fluid intake and flag Incomplete entries to the man- agement team. This system will ensure that detailed, accurate information about the level of as- sistance provided |s recorded at the point of care. Spot Checks through the “Resident of the Day” System: Until Care Vision is fully implemented, the home manager will conduct daily spot checks of care notes as part of the “Resident of the Day” system. These checks will help identify any documentation gaps and ensure corrective ac- tions are taken where necessary. Recruitment of new full-time clinical lead: We have recently recruited a full-time clinical lead at The Meadows, who is now part of our management team. The Introduction of this Clinical Lead will allow the Home Manager to focus more on overseeing the overall operations of the home and strategic planning while ensuring a more effective delegation of clinical responsibilities, The Clinical Lead will provide enhanced support to nursing staff, ensuring that care plans, including mealtime assistance, are regularly reviewed and-accurately documented, This addition to the management team will ensure that care Is delivered according to each resident's needs and that documentation standards are rigorously upheld. 2. Concern Regarding Inaccurate Record of Fluid Intake The coroner's second concern is a false entry In Mr Sparrow’s care notes. The entry indicated that Mr Sparrow had consumed 200m! of tea at 20:30 on 1st December 2023, which was two hours after he had passed away. This raised serious concerns about the accuracy of care records and the possibility that staff were documenting care actions retrospectively, potentially com- promising the safety and well-being of residents. Our Thoughts on the Issue While we acknowledge the inaccuracy of the 20:30 entry, we believe it was the result of late documentation rather than intentional falsification. Staff members sometimes: input care notes after their shifts when using our current care planning system, Fusion, which does not prompt staff to document care In real-time. Care and resident safety tend to be prioritised over adminis- trative tasks, occasionally leading to delays in notetaking. However, we agree that this practice is unacceptable, and the incident has exposed an important weakness In our system that must be addressed immediately. The late entry of care notes is 2 known issue that can lead to mistakes, as demonstrated In Mr Sparrow's case, where 2 staff member from the day shift inputted the 20:30 entry after their shift. Actions Taken and Future Improvements implementation of Care Vision: The new care planning system, Care Vision, will prompt staff to document care activities, including food and fluid intake, at the point of care. This system will fiag if records are not completed in a timely manner, and managers will be alerted to any Incom- plete or delayed entries. Care Vision will be fully operational by January 2025, Reflective Practice and Staff Accountability; All staff have already participated in reflective prac- tice sessions, which focus on the importance of timely and accurate documentation. During these sessions, staff discussed the impact of inaccurate entries on resident safety and the legal and ethical responsibilities they carry in their role. In the future, staff who fail to complete dac- umentation in real time will be subject to disciplinary action, Spot Checks and Monitoring: In the interim, the home manager will continue to Use the “Resi- dent of the Day" system to review daily care notes and ensure that staff complete documenta- tion accurately and in a timely manner, This system provides an immediate layer of oversight while we await the full implementation of Care Vision. Supervision and Mentorship: Senior staff mentor new staff members to ensure they know the importance of recording notes promptly. We will also ensure that staff have the time and sup- port needed to document care without feeling pressured by other duties. 3, Concern Regarding Oversight in Investigation The third concern relates to the internal investigation conducted by the manager of The Mead- ows Nursing Home, EEE following Mr Sparrow’s death. While reviewing his care plan and care notes and speaking to staff, Mrs Hawkins did not identify the false entry madeon Ist December 2023. The coroner expressed concern that this oversight could have delayed iden- tifying the issues raised In concerns 1 and 2. Our Thoughts on the Issue The investigation into Mr Sparrow's death was initiated by the Care Quality Commission (CQC) in December 2023. Ms. Hawkins conducted ’a thorough review based on the information avallable. Her investigation report was submitted to CQC, the local authority (Kerion), and the safeguarding team, all of whom reviewed the findings and raised no concerns. The safeguarding team ultmate- ly closed the case with a single recommendation: to ensure that a duty of candor was exercised with Mr Sparrow’s family Although the error regarding the 20:30 entry was not identified during this investigation, we be- lieve it was an unfortunate oversight rather than a failure of the investigation process. Multiple commissioning and compliance teams reviewed the evidence, and none flagged the error. How- ever, we recognise that this oversight highlights the need for more rigorous review processes and enhanced investigative procedures. Actions Taken and Future Improvements improved Investigative Procedures: Moving forward, all Internal investigations will Involve'a mul- ti-layered review process, ensuring that senior management reviews the findings before reports are finalised, This additional oversight could help prevent essential details from being over- looked. Training for Managers: All home managers, including! will receive further train- ing on conducting investigations, with-a specific focus on reviewing care documentation and identifying discrepancies. This training will ensure that managers are equipped to identify and address potential issues more effectively in the future. Collaborative Reviews with External Bodies: We will continue to work closely with external agen- cles such as CQC, the local authority, and the safeguarding team to ensure thorough, collabora- tive reviews of all future investigations. This will allow for multiple perspectives and additional oversight, reducing the likelihood of errors being missed. Reflective Practice on Investigation Processes; Reflective practice sessions have been held with management to evaluate the investigation Into Mr Sparrow’s care, These sessions have identified several areas for Improvement, including more careful scrutiny of care notes and more transpar- ent communication between staff and management. Patterns and Areas for Improvement Upon reviewing all three concerns, we have identified several common patterns: Documentation: A recurring theme in concerns 2 and 2 is the importance of accurate and timely documentation, Statf must record what care is provided and how itis delivered, including specific details such as the level of assistance during meals. Systemic Oversight: Concern 3 highlights the need for stronger internal-and external oversight during investigations. The failure to detect the entry in Mr Sparrow’s care notes occurred within The Meadows and during multiple externa! reviews. This could suggest a need for better com- Munication and collaboration with external agencies, Technology: Concerns 1 and 2 reveal the limitations of our current care planning system, Fusion, The absence of real-time prompts for staff to record care activities increases the likelihood of late entries, which in turn can lead to inaccuracies. Implementing Care Vision will address this issue directly by ensuring care is recorded at the point of delivery. Reflective Practice: We have conducted reflective practice sessions with our staff and manage- ment team, focusing on the lessons learned from Mr. Sparrow's case, These sessions have been instrumental in identifying areas for improvement and reinforcing the importance of accurate documentation, timely reporting, and thorough Investigations, We are committed to fostering a culture of continuous learning and accountability within our team. Conclusion The Meadows Nursing Home is deeply committed to addressing the concerns raised in the Regu- jation 28 report and ensuring that we provide our residents with the highest standard of cere. The steps we are taking—implementing Care Vision, enhancing our documentation practices, improving investigative procedures, and conducting reflective practice sessions—demonstrate our dedication to learning from this incident and preventing future occurrences. We recognise that the key to our improvement lies not only in the systems we implement but also in the invaluable feedback from our staff. Their insights and experiences are crucial in shap- ing our practices-and ensuring that we continually evolve to meet the needs of our residents: We are fostering a culture of open communication-and collaboration where every team member feels empowered to contribute to our shared goal of excellence in care. While we acknowledge the mistakes made in this case, we firmly believe that the changes we are. implementing will significantly enhance our processes and ensure that our residents receive the care they need and deserve. We extend our sincere condolences to Mr Sparrow's family and re- main committed to acting on the coroner's recommendations as we strive to continuously im- prove our care practices, Weextend our sincere condolences to Mr Sparrow's family and are committed to acting on the coroner's recommendations. Action Plan: Response to Regulation 28 Prevention of Future Deaths Report (Mr. Sparrow) Objective: To address the coroner's concerns regarding Mr. Sparrow's death and Implement necessary improvements to ensure the highest standard of care at The Meadows Nursing Home, 1. Care Plan and Documentation Review Action: * Complete a full review of all resident care plans to ensure they accurately reflect the needs and care provided. * Implement consistent documentation practices for fluctuating levels of assistance, espe- cially during mealtimes. » Responsible Person: Home Manager / Clinical Lead Timeline: + Care plan review completed by 15th October 2024 * Ongoing documentation checks: From 16th October 2024 2. Training on Person-Centered Documentation Action: Provide training to all staff on accurate and detailed documentation, especially regarding levels of mealtime assistance, Ensure training covers the ethical and legal responsibilities of real-time documentation. Responsible Person: Clinical Lead / Training Coordinator Timeline: * Training sessions to be completed by: 30th October 2024 * Follow-up competency assessments; By 15th November 2024 3. implementation of Care Vision System Action: « Finalise the contract and implement Care Vision, a new care planning system that prompts real-time documentation, + Ensureall staff are trained on using the new system effectively. Responsible Person: IT Department / Home Manager Timeline: * Full implementation by 31st January 2025 + Staff training on Care Vision completed by 15th February 2025 4, “Resident of the Day” Spot Checks Action: * Continue daily spot checks of care notes until the Care Vision system Is fully operational. « Focus on identifying gaps in documentation and taking immediate corrective action, Responsible Person; Home Manager Timeline: + Daily checks are to be conducted Immediately, starting 25th September 2024 * Continue until Care Vision is operational: Until 31st January 2025 5. Recruitment of Full-Time Clinical Lead Action: « Ensure the Clinical Lead monitors the accuracy of care plans, documentation, and mealtime assistance. « Assign clear clinical responsibilities to the new lead for oversight of resident care, Responsible Person: Home Manager Timeline: « Clinical Lead in full operational role: Already recruited, ongoing monitoring 6. Addressing Late Documentation Action: + implement an interim system of manual reminders to staff to ensure timely documenta- tion until Care Vision is operational. * \mmediate disciplinary action should be taken against staff members failing to document care in real-time. Responsible Person: Clinical Lead / Home Manager Timeline: + Manual reminder system active: Immediate ¢ Monitoring via “Resident of the Day” system: Ongoing 7. Staff Reflective Practice on Documentation and Accountability Action: * Continue reflective practice sessions for all staff to emphasise the importance of accurate and timely documentation. * Introduce further reflective practice specifically for these involved in Mr. Sparrow's care. Responsible Person: Home Manager / Clinical Lead Timeline: « Reflective practice sessions: Monthly, starting 10th October 2024 8. Improved investigation Procedures Action: « Introduce a multi-layered review process for internal investigations to prevent oversights. * Train all managers on thorough documentation review and the investigation process. Responsible Person: Operations Manager / Home Manager Timeline: * New review procedure established by: 30th November 2024 * Manager training completed by 15th December 2024 9. Collaborative Reviews with External Bodies Action: * Strengthen collaboration with external bodies like COC and the safeguarding team during future investigations. Responsible Person: Home Manager / Compliance Manager Timeline: * Initiate collaboration framework by ist October 2024 * Ongoing for future Investigations 10. Supervision and Mentorship for New Staff Action: * Assign senior staff to mentor and supervise new staff, ensuring they understand the Im- portance of prompt and accurate documentation. * Implement ongoing mentorship to foster accountability, Responsible Person: Clinical Lead Timeline: * Mentorship program to begin: immediately, from 25th September 2024 Conclusion: This action plan ensures timely and effective improvements to address the coroner's concerns, focusing on enhancing documentation accuracy, staff accountability, and care quality, We will monitor progress regularly and adjust timelines as necessary to ensure all actions are completed on schedule. Director
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