Source · Prevention of Future Deaths

Margaret Aitchison

Ref: 2024-0481 Date: 3 Sep 2024 Coroner: N J Mundy Area: South Yorkshire East Responses identified: 2 / 2 View PDF

A critical failure exists in care home fire safety, as staff lack formal systems and training for checking residents after fire alarm activations, despite management claims of improvements.

Date 3 Sep 2024

56-day deadline 29 Oct 2024 est.

Responses identified 2 of 2

Care Home Health related deaths

Coroner's concerns

AI summary

A critical failure exists in care home fire safety, as staff lack formal systems and training for checking residents after fire alarm activations, despite management claims of improvements.

View full coroner's concerns

The evidence from a care worker who was at the home at the relevant time, and remains a care worker at the home, that there are still no formal systems for checking of residents after fire alarm activations, is at odds with the evidence I heard from the care manager that there had been comprehensive changes and a training programme implemented. I am concerned that the processes, protocols and expectations have not been effectively cascaded to those providing care to residents in homes. Accordingly, I invite you to consider the following and in particular whether there is a need for:
1. Further training of senior staff.
2. A requirement for senior staff to each put in place clear processes for staff to respond to fire alarm activations.
3. Training of carers, and any other relevant staff members, in terms of checking resident safety and fire door exits.

Responses

2 respondents

National Care Consortium Ltd

6 Sep 2024 PDF

Noted

The organisation acknowledges receipt of the letter and clarifies the relationship between National Care Consortium and Pristine Care Group Ltd. (AI summary)

View full response

Allow sender Subject: RE: FAO the office of Ms. Mundy- senior Coroner Sent: 06/09/2024, 09:50:20 From: National Care Consortium Ltd To: HMC Doncaster Cc:

Follow Up Flag: Follow up Flag Status: Flagged

Caution! This message was sent from outside your organization. Good morning ,

Thank you very much for your response-. I just want to confirm that the required documents did go to the correct person, our Chairman who is the nominated individual for many of the services within the family portfolio.

National Care Consortium is our umbrella parent company and Broom Lane care home is a part of one of the sister companies within the organisation which comes under the business heading of Pristine Care Group LTD. Thank you for your assistance in this matter.

Kind regards Kelly

From: HMC Doncaster Sent: 05 September 2024 15:24 To: '
- National Care Consortium Ltd' Subject: RE: FAO the office of Ms. Mundy- senior Coroner

Afternoon Kelly Thank you for your email Ms Mundy wishes to clarify is National Care Group part of Pristine Care and did the Reg 28 report go to the correct person.

Kind regards Coroner Support Assistant Corporate Resources Doncaster Council

Good afternoon

I am writing to you today thank you for your correspondence and to acknowledge receipt of the letter from Ms. Mundy dated 3.9.24, along with a copy of the prevention of future deaths- Regulation 28 paperwork.

Can I please respectfully request that the letter be amended to state that Broom Lane is part of Pristine Care Group LTD and not National Care consortium as stated at present.

Many thanks

Kind Regards,

NCC Care Home Support Manager

Pristine Care Group

PDF

Action Taken

The care home has implemented processes and protocols to address identified shortfalls, with auditing duties carried out by the senior management team. A CQC inspector reviewed the protocols and was happy with the improvements. (AI summary)

View full response

Dear Ms Mundy Your Ref Case No: Margaret Aitchison, (Deceased) DOB: 03.08.1943 – DOD: 16.12.2022 I write on behalf of the nominated individual and Chair of the Pristine Care Group Ltd in respect of the case heard by you regarding Mrs Margaret Aitcheson and the resulting issue of a PFD report. I have attached the necessary documents which I feel should answer your concerns you raised in your conclusion. I can conﬁrm and agree with the statement made by my colleague when she gave evidence that the processes and protocols put in place after reviewing the original items are deﬁnitely in place (some of which were with immediate eƯect) and as an organisation we are conﬁdent as we can be that any identiﬁed shortfalls have been addressed and the auditing duties carried out by the senior management team on a regular basis should highlight any discrepancies in the future. I can also conﬁrm that a CQC inspector visited the care home only this week to review the protocols after receiving notiﬁcation from your oƯice and she was more than happy with improvements made. As always the ethos of the organisation is ensuring the safety of our residents is paramount and the lessons learnt have been cascaded to our sister services within the portfolio. I thank you and your oƯicers for your assistance in this matter.

Report sections

Investigation and inquest

On the 3rd January 2023 I commenced an investigation into the death of Margaret Aitchison. The investigation concluded at the end of the inquest . The conclusion of the inquest was: Accidental death 1a Multiple traumatic injuries 1b Fall 1c II Ischaemic heart disease and hypothermia

Circumstances of the death

Margaret Aitchison was a resident in the Broom Lane Care home. Her room was on the first floor of the Sitwell Unit. On the 15th December 2022 at around 10:30 p.m. there was a fire alarm activation. The fire service attended and established that it was a false alarm having being activated by one of the residents. They departed and the maintenance worker came to reset the alarm. There was conflicting evidence as to the resident checks carried out after the alarm had sounded and I found that there were either no or inadequate resident checks following the reactivation of the alarm and furthermore some if not all the fire exits were not checked following the alarm. Although it is not clear whether sleep checks were properly performed on a 2 hourly basis throughout the night, I was able to determine is that at some time after 6:00 a.m. carers discovered that Mrs Aitchison was no longer in her room and after a check of the premises which lasted up to 30 minutes, she was found at the bottom of an unheated stairwell leading to an external fire exit. She had somehow accessed what should have been a locked fire door on the landing area and having gone through, fell down the stairs sustaining traumatic injuries from which she died. She was hypothermic when found (the outside temperature was -5 degrees). I heard evidence that new systems are now in place for checking resident safety and fire door exits after an alarm has sounded and the system has been reactivated but one of the witnesses, who was a carer at the time of the incident and has remained at the home, said that there were still no formal checks and matters hadn't changed.

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2024-0481
Date of report: 3 September 2024
Coroner: N J Mundy
Coroner area: South Yorkshire East

Responses identified

Responses identified 2 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 29 Oct 2024 (estimated).

Sent to

National Care Consortium Ltd

Pristine Care Group Ltd

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.