Source · Prevention of Future Deaths

Douglas Armstrong

Ref: 2024-0440 Date: 12 Aug 2024 Coroner: David Lewis Area: Liverpool and Wirral Responses identified: 1 / 1 View PDF

Care agency responders lacked sufficient training to identify a fractured neck of femur, over-relied on patient self-assessment, and inadequately communicated with ambulance services, resulting in a missed diagnosis.

Date 12 Aug 2024

56-day deadline 7 Oct 2024 est.

Responses identified 1 of 1

Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

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Following his fall at home the Deceased was visited by two representatives of the care agency. They did not appreciate that he had suffered a fractured neck of femur. They placed more reliance than was justified upon his assertion that he had not hurt himself and was not in pain. The information supplied during their verbal communication with the ambulance service did not result in the latter appreciating the need for a personal attendance or visual assessment. Fractured neck of femur is a common consequence of falls in the elderly and requires prompt attention. Those providing a response system should have the skills, knowledge and training necessary to identify the problem or to appreciate that they cannot do so, and to communicate the limits of their diagnostic ability to the ambulance service. I was told that the responders acted in accordance with their existing training and have had no additional training since these events, nor was I told that any is planned. I am concerned that responders attending a similar call might be unable to assist effectively and would appreciate their employers addressing this by considering whether opportunities exist to improve the situation.

Responses

1 respondent

Medequip Other

12 Aug 2024 PDF

Action Taken

Medequip reviewed and updated emergency responder procedures, implemented digital responder forms with risk assessments, completed first aid training for all responders, and is rolling out a bespoke People Manual Handling Training program with completion expected by January 2025. (AI summary)

View full response

Dear Sophie Following the coroner's inquest held on 12 August 2024, we have reviewed the matter referenced above and are providing our formal response in respect to Regulation 28 – Preventing Future Deaths. We have outlined the key actions taken to address the concerns raised: Action 1: Review and Update to Emergency Responder Procedures A thorough review of Medequip’s Responder Service procedures was conducted following the investigation of the incident. This review was completed on 1 July 2024 and included the implementation of a new digital form for recording responder visits and conducting risk assessments for both service users and the environment. These updated procedures are designed to improve the safety and efficiency of responder visits. Action 2: Implementation of Digital Responder Forms To replace the previous paper-based system, we developed digital forms for responder visits in accordance with the TEC Services Association’s Quality Standards Framework. These digital forms incorporate a comprehensive risk assessment to ensure responders are effectively guided throughout their visit. They include follow-up actions, signposting, safeguarding measures, and detailed recording of service user welfare. Additionally, the digital form features a ‘top-to-toe’ physical assessment to help identify potential injuries more thoroughly. This system went live on 1 July 2024, aligned with the revised procedures. Action 3: First Aid Training It was identified that all responders required updated First Aid training. This training was completed and delivered to all responders by 1 April 2024 to ensure they are equipped to provide immediate care when necessary.

Medequip Assistive Technology Ltd. Company Registration No: 4198824 Registered Address: Unit 2, The Summit Centre, Skyport Drive, Harmondsworth, West Drayton, Middlesex, UB7 0LJ Action 4: People Manual Handling Training for Responders A bespoke People Manual Handling Training program has been developed by Medequip Connect. This program, led by a dedicated and qualified trainer, has been designed to enhance the safety and effectiveness of lifting service users, as well as the safe operation of lifting equipment. The training was created in collaboration with Medequip Connect’s National Clinical Lead and includes accredited content. The roll-out of this training is currently underway, with full completion expected by the end of January 2025.

We trust these actions address the concerns outlined in the inquest and demonstrate our commitment to preventing future incidents.

Report sections

Investigation and inquest

On 17 January 2024 I commenced an investigation into the death of Douglas ARMSTRONG aged 88. The investigation concluded at the end of the inquest on 12 August 2024. The conclusion of the inquest was that: On 16 December 2023 the Deceased had an unwitnessed fall at his home address. He sustained a fractured neck of femur, but this was not identified either by two responders from an agency or by the district nurse who attended. As a result his arrival at Arrowe Park Hospital, Arrowe Park Road, Wirral hospital was delayed by around 18 hours, and it is likely that his subsequent surgery was similarly delayed, adding slightly to the mortality risk. He died at the hospital on 5 January due to aspiration pneumonia, which resulted from the accidental injury sustained in the fall. It is unlikely that the delay in hospital admission either caused or materially affected the timing of his death.

Circumstances of the death

On 16 December 2023 the Deceased had an unwitnessed fall at his home address. He sustained a fractured neck of femur, but this was not identified either by two responders from an agency or by the district nurse who attended. As a result his arrival at Arrowe Park Hospital, Arrowe Park Road, Wirral hospital was delayed by around 18 hours, and it is likely that his subsequent surgery was similarly delayed, adding slightly to the mortality risk. He died at the hospital on 5 January due to aspiration pneumonia, which resulted from the accidental injury sustained in the fall. It is unlikely that the delay in hospital admission either caused or materially affected the timing of his death.

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Report details

Reference: 2024-0440
Date of report: 12 August 2024
Coroner: David Lewis
Coroner area: Liverpool and Wirral

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 7 Oct 2024 (estimated).

Sent to

Medequip UK

Source links

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Data: judiciary.uk.

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