Sylvia Nash

Coroner's concerns

AI summary

Insufficient understanding and communication between agencies regarding multi-disciplinary decision-making for patient care, particularly observation removal, led to confusion over responsibilities and incorrect procedures.

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1. It was clear both from the evidence and subsequent correspondence that the correct process for making decisions, such as (but not exclusively), removal of 1:1 observations, is not understood adequately by all parties who should be involved in that decision making process.
2. Whilst the Council understood this to be a multi-disciplinary process involving any professional involved in the patient’s care, the care home, Connaught House, indicated that this decision rests solely with the Council.

3. This is concerning for two reasons. Firstly, the correct procedure is not understood and therefore has not been followed. Secondly, the fact that the care home, where the patient resides is of the view that they are not responsible for making decisions as to removal of observations ahead of transfer. They, in my view, should be pivotal in this decision as the organisation who have had the most contact with the patient and therefore in a position to provide important information as to risk and behaviour.
4. I am concerned that the communication and understanding of the correct process between agencies is insufficient.

Responses

3 respondents

Connaught House

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Noted

Connaught House states they assessed Sylvia required 1:1 supervision and communicated this, but that funding for 1:1 observations is a wider issue. They claim the Regulation 28 order is unfair and not factual against them. (AI summary)

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Dear Ms Ollivere, I am wriƟng in response to the RegulaƟon 28 Order that was made in relaƟon to the sad passing of Sylvia May Nash following a fall at the Orchards Nursing Home and the inquest which took place on the 25th of September 2023. Sylvia was a P2 resident of Connaught House Care Home from the 31st of December 2022 unƟl she leŌ to go to The Orchards Nursing home on the 3rd of February 2023. Sadly Sylvia sustained a fractured neck of femur following a fall at The Orchards Nursing Home on the 11th of March and passed away at Heartlands Hospital on the 14th of April 2023. As the fall occurred some 6 weeks aŌer Sylvia leŌ Connaught House we were not invited to parƟcipate at the inquest and this led to some confusion being created apparently by the evidence given during the inquest. Our care plans and risk assessments were clear that as Sylvia was at high risk of falls and subsequent injury. Sylvia required 1:1 supervision during the day and the use of our assisƟve technology at night and this was communicated consistently to the P2 team and the social work team who queried the need for 1:1 supervision with the OccupaƟonal Therapy team. I note with concern that the Social Worker claimed during the inquest that she was “not sure what the raƟonale for placing Sylvia on one to one care was” as this was always abundantly clear to all as conﬁrmed by our care plans, risk assessments and correspondence with the social worker and wider physiotherapy and occupaƟonal therapy team. We assessed that in order to keep Sylvia safe she required 1:1 supervision whilst awake and the use of our bed and door sensors along with acousƟc monitoring at night. Sylvia was placed in our care for a period of assessment. We made it unambiguously clear that Sylvia required enhanced observaƟons to meet her needs and prevent her from falling. A P2 placement is made in order to fully assess the care needs of an individual in a more appropriate seƫng than a Hospital ward with a view to ascertaining the most suitable placement for long term care. The responsibility for funding lies solely with the commissioners and it is extremely telling that we have not been paid a single penny for the 1:1 care that we provided for Sylvia during her stay with us. The RegulaƟon 28 Order suggests that Connaught House could make some changes to its procedures with respect to the cessaƟon of 1:1 care and we strongly disagree with this conclusion. At no stage did Connaught House remove the 1:1 care for Sylvia and we kept this in place despite not being paid for this expensive provision. The P2 team are fully and solely responsible for the review of the care needs of any individual they place in a P2 bed and for the funding levels available to the new care seƫng they choose to send the resident to. Connaught House can only provide the informaƟon but are not in any posiƟon to dictate this decision in any way, shape or form. Similarly, The Orchards Nursing Home was responsible for assessing Sylvia’s needs and for their decision that despite Sylvia being in receipt of 1:1 care at Connaught House they decided that they could meet her needs without 1:1 enhanced observaƟons. Whilst we have the power to control the delivery of care within Connaught House, unfortunately we do not have the ability to decide the funding levels or care delivered once a resident leaves our care

and it is extremely concerning that seemingly a misleading impression has been given to the Coroner in this regard. We shared our full notes, our assessment of needs, risk assessments and 1:1 paperwork with the Social Workers and The Orchards but unfortunately it appears that The Orchards did not carry out a face to face assessment. The Orchards Nursing Home carried out a telephone assessment and were made fully aware of Sylvia’s care needs and it is incumbent upon all providers of care to carry out a full assessment of needs before accepƟng the placement of a new resident. This assessment is speciﬁcally designed to ensure that the new home has suﬃcient informaƟon to adequately meet the care needs of any new resident. However, should the care home believe that the resident has more signiﬁcant needs than they previously believed it is also their responsibility to increase the care provided in order to meet the needs of the resident. This may involve the provision of 1:1 observaƟons which should be funded by either the ICB or the Council. Similarly, it is the duty of the commissioners to ensure that they meet the assessed care needs of the individuals whose care they fund. In this scenario the only agency that fully discharged its responsibility in respect to the care of Sylvia is Connaught House who provided the care at a loss whilst other agencies seemingly solely focussed on funding levels. In response to the numbered maters of concern:
1. Connaught House did not remove 1:1 observaƟons and indeed provided this care without being paid for its provision. Our decision making process for the provision of 1:1 care is absolutely clear and was followed by us at all Ɵmes as evidenced by our conƟnued provision of the enhanced care deemed necessary by our care plans and risk assessments. Our decision was that Sylvia required 1:1 care during the day and the use of assisƟve technology at night and this was eﬀecƟvely ignored by both the P2 team and The Orchards Care Home. I am unaware as to whether or not The Orchards Nursing Home is equipped with the same type of assisƟve technology but the P2 team and manager of The Orchards would/should be aware of this, and this informaƟon should have played an integral part in the decision making process.
2. I am unsure as to why the Council is suggesƟng that Connaught House, or indeed any other care home, has the power to decide the funding of care delivered by a diﬀerent provider as it is clear from our experience that although we can decide that 1:1 care is necessary whilst a resident is in our care this doesn’t mean that the Council agree to this level of funding or indeed pay the invoices. The decision making process is a mulƟ-disciplinary process solely in the respect of the provision of informaƟon but the decision to fund enhanced care or to make a placement in another care seƫng lies solely with the Council. This has been the case for every single resident that has ever been placed in a P2 bed and I am astounded the Council have now suggested otherwise.
3. We fully understand the procedure for 1:1 funding and have followed it at all Ɵmes. The Order refers to the removal of 1:1 supervision and I reiterate that we did not remove the 1:1 observaƟons which remained in place whilst Sylvia was in our care. Despite being furnished with an abundance of informaƟon surrounding Sylvia’s care, the funding authority and The Orchards Nursing Home decided that Sylvia did not require 1:1 observaƟons. That responsibility and power rests with them and not with us. We desperately wish that we had the ability to demand funding levels for the residents in our care, or indeed the funding for those that leave our care, but sadly this is not the case. We can advise and demonstrate a need for funding but we cannot force the Council or ICB to agree to this funding. In that scenario we can only discharge our responsibiliƟes to the best of our abiliƟes and this is precisely what we did in relaƟon to the care of Sylvia where we conƟnued to provide and

fund the 1:1 observaƟons without being paid for the extra care hours which we, and we alone, believed to be necessary. We did not remove 1:1 observaƟons prior to transfer and provided ample evidence of our assessment that Sylvia required 1:1 care but this evidence was eﬀecƟvely ignored.
4. There is no issue with our communicaƟon or understanding of the need for 1:1 observaƟons and this again was ably demonstrated by the care we delivered to Sylvia and the informaƟon we provided to the wider mulƟ-disciplinary team. I would be extremely interested in the changes the Council have undertaken to adopt in light of this RegulaƟon 28 Order as I believe the issue was not around our provision of informaƟon but rather whether there was an acceptance that this level of care was required or whether the Council could ﬁnd an alternaƟve placement that was cheaper. Connaught House did not decide that Sylvia needed to leave its care and nor did we decide that these 1:1 observaƟons were not required. This decision was taken by others. In conclusion I do believe the issue of commissioners refusing to conƟnue to fund 1:1 observaƟons is a huge issue for the care of our most vulnerable residents and sadly this is repeated across every area we operate care homes in. Indeed, in other areas, ICB Commissioners are now dictaƟng that they will only fund 20 hours of 1:1 observaƟons per day despite agreeing that the resident requires 24 hours of 1:1 observaƟons and use the excuse that they will sleep at some point during the 24 hour period. This is quite simply unsafe and as an organisaƟon we refuse to agree to this but other organisaƟons will acquiesce as there is an imbalance of power between the commissioner and the provider. I do not believe that it is within our power to make any changes to the way that funding is assessed or agreed by the Council or the ICB and we will conƟnue to provide 1:1 care where we have assessed that it is required and conƟnue to advocate for the residents in our care. As I believe there is a wider issue surrounding the issue of removal of funding for 1:1 placements, I would welcome a further discussion with the Coroner and do believe that future deaths can be prevented. Unfortunately, during the inquest the Coroner was not furnished with the correct informaƟon regarding the process surrounding the funding or removal of 1:1 observaƟons and as a result the RegulaƟon 28 Order does not target the root of the problem. I would really appreciate the RegulaƟon 28 Order needs to be reviewed as I feel it is unfair and not factual against Connaught House. I also want to make you aware this sƟll conƟnues to happen from the local authority, only last week did a family come in to collect their relaƟve from a P2 bed and we had not been informed by the social worker, when we rang the Social worker they advised they had asked the family to inform us, yet we are responsible for discharge paperwork, ordering medicaƟon etc. It is a clear failure on the ICB and Local authority, not Connaught House.

Birmingham City Council Local Authority / Fire Service

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Action Taken

BCC has conducted staff engagement sessions and provided a template for recording multi-disciplinary decision making. The ICB is leading on developing procedures around 1 to 1 support in P2 beds, stating that it can only be removed following an MDT decision. (AI summary)

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REPORT FOR HER MAJESTY’S CORONER FOR THE BIRMINGHAM AND SOLIHULL AREAS Re: (Sylvia Nash) (deceased) DATE OF BIRTH: 30/05/1940 DATE OF DEATH: 14/04/2023 ADDRESS - LATE OF: The Orchards Care Home, 164 Shard End Crescent, Shard End, Birmingham B34 7BP OFFICIAL

Report prepared by:

Role: Head of Service - Hospital and Discharge to Assess Pathways

Background This response is provided by Birmingham City Council (BCC) further to the Regulation 28 Report issued by HM Assistant Coroner Rebecca Ollivere on 2 January 2024. I would like to start by expressing our condolences to Sylvia’s family for their sad loss. The Assistant Coroner explained in the Report that she is concerned that the communication and understanding of the correct process between agencies around decision making is insufficient. Prior to the report being issued, BCC had written to the Assistant Coroner acknowledging shortcomings which had existed at the time and setting out in detail the changes which have been made to its processes since. That already being the case, the Assistant Coroner has requested that BCC’s Regulation 28 response should address only the issue of communication between services. BCC Social Workers work alongside partner agencies and professionals to support the social work assessment process, as an example, they will refer citizens to therapy services and then on receipt of the therapy report, review the recommendations and use them to underpin and provide an evidence base as part of their own Social Work (“SW”) assessment. Information sharing between partner agencies takes place in a variety of forms depending upon the service. There may be daily board rounds, tracker meetings or Multi-Disciplinary Teams (“MDT”). The purpose is to ensure that all professionals supporting the citizen have a full understanding of all of their care and support needs, so this includes both health and social care needs. It is also an opportunity to identify if there may be any disagreements between professionals and what actions are required in order to ensure a safe discharge. Citizens will be discussed within the MDT at various stages of their assessment journey – for instance following a therapy assessment, the MDT will be updated about their mobility needs, following a capacity assessment, the MDT will be updated about the citizen’s capacity etc. Where there is a disagreement around a citizens’ care needs, there needs to be a discussion within the MDT based on evidence. The expectation is that a consensus can be reached within the MDT, if this is not possible, then any concerns need to be clearly documented on the OFFICIAL

citizens care record. There are, at times, different professional perspectives. Social Workers are aware that if these cannot be resolved, they need to be very clear about their own decision- making process and escalate when necessary to their line manager. Any decisions made need to include any risk mitigations where appropriate and again these need to be recorded on the care record. There may be a requirement for a Continuing Health Care assessment to identify any primary health care needs; the outcome of this will also inform the SW assessment and support with discharge planning. This is a separate multi-disciplinary process led by health and affords an additional opportunity for multi-disciplinary discussions. Once all assessments have been concluded, the MDT will be updated about the next stage in the process. This may lead to a commissioned service and the MDT will be notified about any offers received via Local Authority brokerage. Where a care home is being explored, the SW will send a copy of the support plan via email to the potential provider and follow up with a telephone call to arrange the pre-admission assessment. They will also advise the existing service that a pre-admission assessment has been arranged. The pre-admission assessments may be face to face or a telephone assessment. It is the responsibility of the Social Worker to ensure that the support plan is up to date, and an accurate reflection of the citizen’s care needs and it is the responsibility of the existing service to provide a full and comprehensive handover for any pre-admission assessment. Once a citizen’s care provider has been finalised, the MDT will be updated, and the discharge will be arranged. If a professional has concerns around the proposed discharge, these would be explored and again during the board round/tracker/MDT meetings and should be recorded on the citizens’ care record. All professionals working with the citizen will be aware that the citizen has an allocated social worker and the contact details for that worker. Information is shared between services in a variety of ways including face to face discussions, telephone calls, emails and reports. The expectation is that the citizens care record is kept up to date to reflect the information sharing between the agencies involved in the assessment/discharge planning process. In Sylvia’s case, the care record does not evidence the multi-disciplinary input and decision- making process. To address this, there have been staff engagement sessions and discussions with the Social Work staff around evidencing the multi-disciplinary decision making. There is now a template that workers need to complete to record the discussion, any agreed actions, and any risk mitigations. OFFICIAL

Sylvia was a self-funder whilst living at The Orchards, and the care arrangements were made by the family and an independent broker. BCC has a duty to complete the SW assessment for self-funders, this can then be shared with potential providers who will complete their own pre-admission assessment. This was the process followed for Sylvia. BCC has worked with colleagues in the Integrated Care Board (ICB) to develop procedures around 1 to 1 support. The P2 (assessment) beds that Sylvia stayed in at Connaught House are funded by the ICB, so the ICB are taking a lead on developing this and embedding the new procedures across P2 beds. The procedure now clearly states that 1 to 1 support can only be removed following an MDT decision involving the care home nurse, social worker, and the clinical need. BCC does not use Connaught House for P2 provision. However, the ICB when required does spot purchase beds at Connaught House, which the ICB then oversees. Discussions have taken place between Connaught House and the ICB to ensure Connaught House understands that responsibility for removing 1 to 1 support does not sit with the BCC P2 team but is an MDT decision, which should include the care home nurse, clinical lead, and the social worker. OFFICIAL

Connaught House

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Action Taken

Connaught House has cascaded information about a new ICB process for removing 1:1 support to their staff and placed posters in each nursing station to ensure awareness. (AI summary)

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Dear Ms Ollivere,

Thank you for your follow up letter dated the 18th of March and for the opportunity to comment further.

The email correspondence you kindly enclosed shows that Sylvia’s 1:1 observations were to be removed on the 3rd of February which was also the planned discharge date from Connaught House. To reiterate, Sylvia remained on her 1:1 observations whilst in our care at Connaught House.

Had Sylvia not been due to leave our care on the 3rd of February we would have requested that we continue to have the 1:1 in place but monitor Sylvia from a distance for up to a week to ensure that the removal of the 1:1 was appropriate in our care setting at that time and did not pose a risk to Sylvia’s safety. We would then have reconvened with the Social Worker to discuss the result of monitoring Sylvia from a distance. This is a procedure we routinely follow when asked to remove 1:1 care in each of our homes.

As we outlined in our previous response the agreement to provide 1:1 observations is often a source of conflict between care homes and commissioners and there is often pressure to remove the enhanced observations. This is especially true when the resident who is in receipt of enhanced observations is settled as a result of this enhanced care.

This was the situation with Sylvia and her 1:1 paperwork evidenced that she was settled for the majority of the time. It was our contention that she was settled as a result of the 1:1 observations and this was discussed with the social worker during discussions around the need for this enhanced care.

The social worker was of the view that Sylvia did not need 1:1 care as her 1:1 paperwork reflected that she was settled for large periods. We contend that this was evidence of a well-met need but it is also true that the social worker was involved in making the placement at the Orchards Nursing Home and was in possession of information we did not have. For instance, following their pre-admission assessment, the Orchards Nursing Home may have decided that due to the fact that Sylvia was on 1:1 care during the day she may be placed in a bedroom directly opposite the Nurse’s Station where she could be closely monitored. This is a clinical decision for another setting and we are not aware of their decision making process or what steps they had planned to take following their assessment.

Our clinical decision was that Sylvia required 1:1 observations whilst in our care. We continually reevaluated and this was reduced to 12 hours during the day as we utilised our assistive technology during the night. It was the clinical decision of the Orchards Nursing Home that they could meet her assessed needs without the need for 1:1 supervision. It is worth noting that Sylvia was a resident of the Orchards Nursing Home for slightly longer that she was at Connaught House and any clinical decision should be subject to constant review. If they felt at any stage that Sylvia required 1:1 care then it was their responsibility to seek authorisation.

We share your concerns regarding the MDT process regarding the removal of 1:1 funding and were very pleased to receive an email on Thursday 21st of March outlining a new process adopted by the ICB:

OFFICIAL “The ICB have put a new process in place whereby 1:1 can only be removed after our reviewer has discussed the safety of potential removal with the Care Home Nurse and the Social Worker. One person can’t remove the 1:1 in isolation.”

We have ensured that this has been cascaded to our staff team and a poster has been placed in each nursing station to ensure that all involved in any 1:1 review are fully aware of this new process. We will also ensure that any visiting professional also fully considers the potential impact of the removal of 1:1 observations.

Should you require any further information please do not hesitate to contact me.

Report sections

Investigation and inquest

On 24 April 2023, I commenced an investigation into the death of Sylvia May NASH. The investigation concluded at the end of the inquest on 25th September 2023 . The conclusion of the inquest was; Accident

Circumstances of the death

On 11th March 2023, the deceased fell at The Orchards Nursing Home where she resided. She was taken to Birmingham Heartlands Hospital where she underwent surgical fixation of a fractured neck of femur sustained in that fall. Post operatively, she developed septic shock, and despite treatment, continued to deteriorate. She died in hospital on 14th April 2023. Based on information from the Deceased’s treating clinicians the medical cause of death was determined to be: 1a Sepsis 1b Prosthetic joint infection 1c II Fractured neck of femur operated, Lewy Body Dementia

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