Care Outlook
Other
Action Taken
Care Outlook has implemented mandatory Basic Life Support training with a choking vest, expanded their nutrition and hydration assessment to include an 'Eating and Drinking Checklist' highlighting choking risk, and increased the frequency of e-learning on Dysphagia and Modified Diets to annually. (AI summary)
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Care Outlook Ltd Response to Coroners Report in respect of Mr Alan Lee
Date of coroners report: 06/06/2024 Ref: 2024-0308 Deceased name: Alan Lee Coroner name: Penelope Schofield Coroner Area: West Sussex, Brighton and Hove
Background
Mr Alan Lee (AL) lived in his home, at Abbotswood extra care scheme in Rustington, West Sussex.
AL was supported by Care Outlook who were commissioned by West Sussex County Council to provide 4 visits per day to assist with personal care and daily living activities. Care Outlook had been the care provider for AL since 11/09/2023.
AL would usually go down to the dining room daily for his lunch and was escorted by care staff to go to the dining room and to return after eating; care staff did not remain with AL while in the dining room and he would eat independently. On occasion AL would prefer to eat his lunch in his home and when that was his preference care staff would deliver his lunch to him and then leave him to eat independently.
AL had no known history of choking and ate his meals independently.
Coroners Report
CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows: (brief summary of matters of concern)
The issue of concern is that despite the fact that Mr Lee had recently been given his dinner and there was evidence that some or part of it had been consumed, the staff who attended, following Mr Lee using his alarm, did not appear to consider that he may have been choking. Therefore, no life saving techniques were attempted.
ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or 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 August 01, 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.
Response
Prior to this incident our staff received both theory and practical training on Dysphagia and modified diets and Basic Life Support (BLS); this training is a blended learning approach of e-learning and classroom based.
BLS training included choking risks and responses with practical demonstrations of appropriate actions including “back strikes” and “abdominal thrusts”. Dysphagia and modified diets training included causes and effects of swallowing difficulties, signs of choking and appropriate action to be taken in the event of choking.
The staff we employ at our services are not medically trained personnel and there will always be limits to their ability to identify the causes of a medical emergency, however our training is designed to support the provision of immediate and basic life saving techniques where appropriate.
We have reviewed our training provision and have made some changes in the design and delivery of this to strengthen the courses and to provide staff with greater confidence in the future.
Action Detail Purchase of a choking vest The training team purchased a Choking Vest to incorporate into the practical BLS training we deliver.
BLS training has always included choking risks and responses with practical demonstrations of appropriate actions including “back strikes” and “abdominal thrusts”, the Choking Vest provides an additional tool for staff to be able to carry out a more hands on practice of these actions.
For information – this is a link to the type of device purchased: https://shop.rlss.org.uk/products/choking- rescue-trainer-vest
Development of training plan The training team developed a lesson plan for the delivery of the additional practical element of the choking training which can be delivered as a standalone session and can be incorporated into the existing BLS training session currently delivered during induction and refresher training.
Training includes the signs / symptoms & actions in the event of choking.
The trainer delivers a section on how a person might present physically/visually if they are choking and how this may differ from other causes.
The training covers choking for people in a variety of reposes including sitting, standing and laying down.
The training includes a practical demonstration by the trainer of actions to take in the event of choking, using the Choking Vest as a training tool. Trainees are then required to practice these actions using the Choking Vest under the guidance of the trainer.
Action Detail Roll out of training with choking vest The new practical session was rolled out to services as a standalone session beginning on 01/07/2024.
Services in West Sussex were prioritised for the delivery of these sessions; delivery in West Sussex was completed on 24/07/2024.
In addition, the training team are creating a recorded session with practical demonstrations using the choking vest which will be available to all staff across the business online and will be accessible at any time for refreshers via our e-learning platform. The recording has been completed and is now in the editing stages with the intention to have this live on the system before the end of August 2024.
Incorporation of choking vest training to induction and refresher As noted above the lesson plan created by the training team can be delivered standalone or as part of the existing mandatory BLS training delivered during induction and refresher training.
The amended lesson plan for all BLS training has been active since 09/07/2024 and from this time all new staff attending Induction training will receive the updated training with the choking vest and all staff attending refresher training will also receive the updated training with the choking vest.
Increased frequency of e- learning All staff complete e-learning on Dysphagia and Modified Diets as part of their Induction. This training has been set to an increased refresher frequency of annually.
This training covers causes and effects of swallowing difficulties, signs of choking and appropriate action to be taken in the event of choking.
Action Detail Expansion on eating and drinking risk assessment We have expanded our nutrition and hydration assessment to include a standalone risk assessment tool of an ‘Eating and Drinking Checklist’. This assessment document provides additional, specific questions to highlight choking risk and record involvement from health care professionals such as the SALT Team.
This information was previously recorded within the Needs Assessment under Nutrition and Hydration; we are now providing this as a separate document and enhancing with specific questions highlighting risk of choking and the control measures needed to manage this risk.
The use of this new document will be rolled out to all services by the end of August 2024.
Date of coroners report: 06/06/2024 Ref: 2024-0308 Deceased name: Alan Lee Coroner name: Penelope Schofield Coroner Area: West Sussex, Brighton and Hove
Background
Mr Alan Lee (AL) lived in his home, at Abbotswood extra care scheme in Rustington, West Sussex.
AL was supported by Care Outlook who were commissioned by West Sussex County Council to provide 4 visits per day to assist with personal care and daily living activities. Care Outlook had been the care provider for AL since 11/09/2023.
AL would usually go down to the dining room daily for his lunch and was escorted by care staff to go to the dining room and to return after eating; care staff did not remain with AL while in the dining room and he would eat independently. On occasion AL would prefer to eat his lunch in his home and when that was his preference care staff would deliver his lunch to him and then leave him to eat independently.
AL had no known history of choking and ate his meals independently.
Coroners Report
CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows: (brief summary of matters of concern)
The issue of concern is that despite the fact that Mr Lee had recently been given his dinner and there was evidence that some or part of it had been consumed, the staff who attended, following Mr Lee using his alarm, did not appear to consider that he may have been choking. Therefore, no life saving techniques were attempted.
ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or 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 August 01, 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.
Response
Prior to this incident our staff received both theory and practical training on Dysphagia and modified diets and Basic Life Support (BLS); this training is a blended learning approach of e-learning and classroom based.
BLS training included choking risks and responses with practical demonstrations of appropriate actions including “back strikes” and “abdominal thrusts”. Dysphagia and modified diets training included causes and effects of swallowing difficulties, signs of choking and appropriate action to be taken in the event of choking.
The staff we employ at our services are not medically trained personnel and there will always be limits to their ability to identify the causes of a medical emergency, however our training is designed to support the provision of immediate and basic life saving techniques where appropriate.
We have reviewed our training provision and have made some changes in the design and delivery of this to strengthen the courses and to provide staff with greater confidence in the future.
Action Detail Purchase of a choking vest The training team purchased a Choking Vest to incorporate into the practical BLS training we deliver.
BLS training has always included choking risks and responses with practical demonstrations of appropriate actions including “back strikes” and “abdominal thrusts”, the Choking Vest provides an additional tool for staff to be able to carry out a more hands on practice of these actions.
For information – this is a link to the type of device purchased: https://shop.rlss.org.uk/products/choking- rescue-trainer-vest
Development of training plan The training team developed a lesson plan for the delivery of the additional practical element of the choking training which can be delivered as a standalone session and can be incorporated into the existing BLS training session currently delivered during induction and refresher training.
Training includes the signs / symptoms & actions in the event of choking.
The trainer delivers a section on how a person might present physically/visually if they are choking and how this may differ from other causes.
The training covers choking for people in a variety of reposes including sitting, standing and laying down.
The training includes a practical demonstration by the trainer of actions to take in the event of choking, using the Choking Vest as a training tool. Trainees are then required to practice these actions using the Choking Vest under the guidance of the trainer.
Action Detail Roll out of training with choking vest The new practical session was rolled out to services as a standalone session beginning on 01/07/2024.
Services in West Sussex were prioritised for the delivery of these sessions; delivery in West Sussex was completed on 24/07/2024.
In addition, the training team are creating a recorded session with practical demonstrations using the choking vest which will be available to all staff across the business online and will be accessible at any time for refreshers via our e-learning platform. The recording has been completed and is now in the editing stages with the intention to have this live on the system before the end of August 2024.
Incorporation of choking vest training to induction and refresher As noted above the lesson plan created by the training team can be delivered standalone or as part of the existing mandatory BLS training delivered during induction and refresher training.
The amended lesson plan for all BLS training has been active since 09/07/2024 and from this time all new staff attending Induction training will receive the updated training with the choking vest and all staff attending refresher training will also receive the updated training with the choking vest.
Increased frequency of e- learning All staff complete e-learning on Dysphagia and Modified Diets as part of their Induction. This training has been set to an increased refresher frequency of annually.
This training covers causes and effects of swallowing difficulties, signs of choking and appropriate action to be taken in the event of choking.
Action Detail Expansion on eating and drinking risk assessment We have expanded our nutrition and hydration assessment to include a standalone risk assessment tool of an ‘Eating and Drinking Checklist’. This assessment document provides additional, specific questions to highlight choking risk and record involvement from health care professionals such as the SALT Team.
This information was previously recorded within the Needs Assessment under Nutrition and Hydration; we are now providing this as a separate document and enhancing with specific questions highlighting risk of choking and the control measures needed to manage this risk.
The use of this new document will be rolled out to all services by the end of August 2024.