Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, written 26 Oct 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Oct 2015 |
|---|---|
| Deceased | Allan Beasley |
| Coroner | Louise Hunt |
| Coroner area | Birmingham and Solihull |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Sunrise care home
1 | CORONER
{am Louise Hunt, senior coroner, for the coroner area of Birmingham and Solihull
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.
3 | INVESTIGATION and INQUEST
On 17/07/15 | commenced an investigation into the death of Allan Richard Beasley. The
investigation concluded at the end of the inquest on 22/10/15. The conclusion of the
inquest was:
The deceased died from a traumatic cervical spine fracture following 7 falls. The initial risk
assessment was inadequate. There was a failure to correctly document the falls as they
occurred. The risk assessment was not updated and there was no referral to the falls
team for further assessment. These failures contributed to his death..
4 | CIRCUMSTANCES OF THE DEATH
The deceased suffered from vascular dementia. He was admitted to Sunrise care home
on 21/05/15 as he could no longer manage at home. An initial moving and handling
assessment confirmed that he could mobilise with 2 sticks but he needed supervision. He
was noted to be unsteady on his feet at times.
After admission he had a number of falls.
03/06/15 at 15.00 — the deceased was walking to the lounge with his son and lost his
balance and fell with no injuries.
13/06/15 — the deceased had two falls. At 08.30 he was found on the bedroom floor
shouting for help and he had grazed his right forearm. At 09.30 he was found on the floor
with a skin tear to the right wrist.
17/06/15 at 12.00 — he was found on the floor in the corridor with no injuries.
22/06/15 — no incident form but the deceased was noted to have been found on the floor
near his bed and had defecated on the carpet.
29/06/15 no time recorded — He was walking alongside another resident when there was
some sort of altercation with that resident and the deceased fell and grazed his head and
bruised his eye. The incident was reported to the police and no further action taken.
On 04/07/15 he suffered a further unwitnessed fall in the dining area. He was admitted to
Birmingham Heartlands Hospital the same day. A CT scan confirmed C1 burst cervical
fracture and a fracture of the odontoid process named as a type 2 odontoid peg fracture.
He was treated with a collar but due to his vascular dementia he kept removing the collar.
He developed a chest infection. He continued to deteriorate and passed away on
09/07/15.
An external review after the events confirmed the following:
¢ The initial risk assessment did not indicate all the risk factors which may
contribute to fails.
e There is no evidence the initial documents were ever reviewed or that the deputy
manager was aware of the number of falls.
e _ Staff failed to follow the falls prevention policy and failed to correctly record
incidents.
e The monthly wellness check was not completed at the end of June 2015, and the
monthly falls analysis log was not completed.
e An uneven floor may have contributed to the fall.
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) Staff were unaware of the Home's Falls Prevention Policy. This meant staff failed
to correctly record falls and escalate to appropriate senior staff.
(2) The falls monthly log was not completed on a daily basis as it should have been.
The log was not completed for June as staff were too busy. This resulted in trends
being missed and staff being unaware of the frequency of Mr Beasley's falls.
(3) 15 minute observation forms were found to be inaccurate as staff in the office
were completing the form when not seeing the patient. In addition the observation
forms were felt to be inaccurate as a member of staff signed for observations
when it was found they were undertaking another task.
(4) Documentation is not completed contemporaneously but at the end of the shift.
(5) The home has a policy that the first fall of a resident is treated as an isolated
incident and no further action is taken.
(6) The home has a policy that they only escalate to the falls team if a resident has
had 3 falls.
(7) The falls tracker was not completed for Mr Beasley.
(8) The falls incident forms were not correctly reviewed by senior staff.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe your
organisation have the power to take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 21 December 2015. |, 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
| have sent a copy of my report to the Chief Coroner, the family, Care Quality Commission
and West Midlands Police.
| 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.
26th October 2015
Bathe
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