Evelyn Burcham

Coroner's concerns

AI summary

Care homes failed to foresee the risk of cognitively impaired residents misusing riser-recliner chair controls, and there are no regulatory or manufacturing standards for safer remote control features.

View full coroner's concerns

I am concerned that these chairs are common place in care home settings where residents suffer from cognitive impairment. The risks of another resident with dementia accessing the controls of the riser-recliner chair(s) was not foreseen by the Home and so was not factored into any operative risk assessment at the time; hence no measures were in place to minimise the risk. There remains a real and immediate risk that those with a cognitive impairment that manifests itself in a compulsion to fiddle and/or press buttons, can create a risk of death to other residents in the same care facility or setting. If this particular care home group did not foresee the risk then it is likely that others have not foreseen it either. I was told at the Home had made enquiries with manufacturers of these standard riser-recliner chairs about the ability to ‘lock’ the remote control and/or find a safe was of storing it so that it is not accessible to anyone who does not have the authority, training or appropriate cognitive function to be able to use it safely. It would appear that a chair with a ‘safe’ remote cannot be purchased by the Home and there do not appear to be any regulatory or manufacturing standards (over and above manufacturing standards for consumers) that require these types of chairs to have this, or some alternative, safety feature that limits the use of the controls. I was told that the only way to render the remote ‘safe’ was to turn the power off at the mains, which in itself could create health and safety issues if the chair needed to be operated quickly.

Responses

4 respondents

Aria Care

17 Nov 2023 PDF

Action Taken

Aria Care will direct all future requests for riser/recliner chairs to Shackleton's, ensuring lockable handsets, and inform newly admitted residents of this requirement from December 1st, 2023. They are also working to replace existing chairs without lockable handsets and will reduce the use of riser/recliner chairs across the organization. (AI summary)

View full response

Dear Mrs Marsh I write further to the Inquest into the death of Mrs Evelyn Ann Burcham, 27th September 2023 and your request that within 56 days Aria Care provide a response to the following matters: a) the results of discussions with manufacturers about lockable controls; and b) Following the Quarterly meeting, any other ideas from Aria about how to reduce this risk. Following receipt of the request, Aria Care reached out to Shackleton’s, our furniture supply partner seeking advice and guidance on riser/recliner chairs and the potential for purchase and supply of handsets that could be locked in a secure position and avoid unauthorised access and repositioning. Shackleton’s advised that due to the large number of riser/recliner manufacturers that a single universal handset, with a lockable feature, was not possible to supply, however, they are able to provide a lockable handset for the chairs they supply. We have trialled this control with other chairs and have had mixed results, with 15% of the chairs tested not suited to the Shackleton’s supplied handset. We have now directed that all future request for the supply of riser/recliner chairs will be processed via Shackleton’s and that all chairs supplied to Aria Care will be fitted with lockable handsets. From the 01st December 2023, residents being newly admitted to the home will be made aware of the Aria Care’s requirement for all privately purchased riser/recliner chairs to come fitted with lockable handsets. Where residents are currently living in our care homes and have purchased privately their riser/recliner chair, and this device is not fitted with a lockable handset, we will work with that resident and/or their family to seek a solution and ensure the riser/recliner is replaced by a chair that has a lockable handset. We anticipate this may take the first quarter of 2024 to fully resolve, where the equipment supplied is privately owned and already in use. In the meantime, our property services department are working with NH Maintenance (NHM), to explore other options, including the development of a cover that could potentially be used universally, to restrict access to the handset controls, this device would be lockable.

Whilst NHM state they would be able to deliver such a device, they have indicated that development and trial takes time and that they may not be able to provide an immediate short-term solution but could within 2-3 months provide a universal lockable cover. Whilst waiting on the development by NHM, we will look to use the controls provided by Shackelton’s to reduce unauthorised access to riser/recliner chair controls, where they are compatible. For chairs where we cannot control access via the introduction of the covers, we have introduced generic and individualised risk assessments which include the requirement to:  maintained a safe distance between the riser/recliner and other seating, reducing access to handsets.  where a resident lacks the physical or cognitive ability to independently control the riser/recliner chair, that once positioned comfortably colleagues will isolate the electrical flow to the chair preventing unauthorised access and repositioning. Aria Care are committed to delivering a long-term solution to this problem, but have encountered challenges, due to the variety of chairs available across the national marketplace. We are also aware that any decision taken, regarding existing riser/recliner chairs needs to consider those chairs owned or purchased privately and that we will need to liaise with residents and their families to transition to the supply of lockable handsets only devices within our homes. We have also reached out to the Care Quality Commission, via our corporate link, seeking the Commissions view in regard to our risk reduction approach and specifically any concerns where our plans or approach might impact residents’ rights in relation to restrictive practices and how we ensure we deliver the correct balance between safety and restriction. At our Quarterly Quality Assurance Meeting the adverse event involving Mrs Burcham was revisited, and the following outcomes agreed:
1) Introduction of generic risk assessment for colleagues to support the safe use of riser/recliner chairs. This document provides a general guide to colleagues on measures to be taken to safely use and maintain a riser/recliner chair, without taking into consideration the specific and unique needs of the person using the equipment.
2) Introduction of resident specific risk assessment for suitability to use a riser/recliner chair. This document builds on the generic risk assessment and provides details for colleagues of how to support individual residents use the equipment safely based on their physical and cognitive abilities and support needs.
3) Introduction of an asset register for riser/recliner chair use/deployment, be that supplied by Aria Care or specifically purchased by the resident or their family.
4) Completion of an organisational wide survey to understand the extent and supply of riser/recliner within Aria Care.
5) Agreement that via a phased approach Aria Care will reduce the use of riser/recliner chairs across the organisation and where an assessed need exists, riser/recliner furniture will be purchased solely from Shackleton’s, as our furniture partner, with lockable handsets. We trust that the actions we have taken and those we propose to take provide assurance of our commitment to resident safety and wellbeing. Every effort is being made to reduce the risks

associated to the supply and correct use of riser/recliner chairs within our homes and we will continue to seek additional control measures to further mitigate risks to people living in our homes and to learn from adverse events, such as this and the sad loss of Mrs Burcham.

Health and Safety Executives Regulator / Inspectorate

19 Dec 2023 PDF

Noted

HSE outlines the regulatory regimes applicable to the circumstances. HSE has contacted CQC on the patient safety aspects and notified OPSS regarding consumer product safety. (AI summary)

View full response

Dear Madam REGULATION 28 PREVENTION OF FUTURE DEATH – RECLINER CHAIR Thank you for your report sent to , HSE Chief Executive, in relation to the death of Mrs Burcham of Frethey House Nursing Home. Mrs Burcham suffered a head injury when she fell from a standard riser-recliner chair after it was operated by another resident, while unattended by nursing home staff. I am responding as the Head of Local Authority and Safety Unit at the Health and Safety Executive (HSE) which leads on workplace product safety. Your report highlights, as matters of concern, that these chairs are commonplace in care home settings where residents suffer from cognitive impairment that manifests itself in a compulsion to fiddle and/or press buttons, and that the risk of other residents with dementia accessing the controls was unforeseen. This did not feature in any risk assessment undertaken by the home and therefore measures were not put in place to address this risk. There are a number of regulatory regimes that may be applicable to the circumstances, and I provide some detail on these below. In England, the Care Quality Commission (CQC) is the lead inspection and enforcement body for safety and quality of treatment and care matters involving patients and service users in receipt of a health or adult social care service from a provider registered with CQC. The Memorandum of Understanding between CQC and HSE explains the respective roles and responsibilities of each organisation with regard to health and safety incidents in the health and adult social care sectors. This means that, in general, where care homes are registered with CQC, then CQC will be responsible for regulating the safety, quality of treatment and care matters involving service users and patients. HSE or the Local Authority will be responsible for the health and safety matters involving workers, visitors and contractors. HSE is the enforcing authority for care homes with nursing where the main activity is the provision of nursing/medical care. Local Authorities are the enforcing authority for care homes where the main activity is the provision of residential accommodation.  The Health and Safety

2 (Enforcing Authority) Regulations 1998 set out the enforcement allocation of workplaces between Local Authorities and HSE. As this case involves a service user/patient it would not be a matter for HSE enforcement and would instead fall within the remit of CQC. With regard to product safety matters, the chair involved in this tragic incident would appear to meet the definition of a ‘machine’, and therefore the relevant supply legislation would be the Supply of Machinery (Safety) Regulations 2008, which implemented the EU Machinery Directive 2006/42/EC in GB. HSE is responsible for the enforcement in respect of unsafe workplace machinery placed on the market in GB. However, for consumer products, it is Trading Standards. Standard riser-recliner chairs are widely used domestically. If anyone can purchase the chair for use at home then it would normally be considered as a consumer product and be regulated by local authority Trading Standards. After receiving your report, HSE contacted the other regulatory bodies who may have an interest or potential regulatory role in respect of this incident. We have written to CQC (who are already in receipt of your report) on the patient safety aspects. HSE has also notified the Office for Product Safety and Standards (OPSS) who are the national regulator for consumer products and who work with the local authority Trading Standards services that undertake most enforcement activity. I would seek your permission to share your report with OPSS who will be able to consider the consumer safety aspects and liaise with Trading Standards as appropriate. Alternatively, you may contact OPSS directly at the following address: Graham Russell, Chief Executive Officer, The Office for Product Safety and Standards, Dept. for Business and Trade, 4th Floor Cannon House, 18 The Priory, Queensway, Birmingham, B4 6BS. I hope that the above information is of assistance and addresses the matters raised.

Department of Health and Social Care Central Government

26 Apr 2024 PDF

Noted

The Department of Health and Social Care acknowledges the concerns, notes the CQC's investigation and outcome, and mentions Aria Care's move to use lockable remotes on riser-recliner chairs. (AI summary)

View full response

Dear Ms Samantha Marsh,

Thank you for your Regulation 28 report to prevent future deaths dated 31/10/2023 about the death of Evelyn Ann Burcham. I am replying as Minister with responsibility for adult social care.

Firstly, I would like to say how saddened I was to read of the circumstances of Ms Burcham’s death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for the delay in responding to this matter.

Your report raises concerns over electric riser-recline chairs which are commonplace in care home settings, including where residents suffer from cognitive impairment, and the risks of another resident with dementia accessing the controls of the chair(s). The report also raises concerns about the ability, or lack of ability, to ‘lock’ the remote control and/or find a safe way of storing it so that it is not accessible to anyone who does not have the authority, training or appropriate cognitive function to be able to use it safely.

In preparing this response, Departmental officials have made enquiries with NHS England and the Care Quality Commission (CQC).

The Department is content that the CQC have discussed the case internally on 06/01/23, including actions taken to date and proposed future actions. It was agreed that further information was required from the provider about the incident. CQC received the information requested and held further internal discussion on 13/02/23. CQC assessed that there was sufficient evidence to refer the incident to the Criminal Enforcement Support Hub (CESH) prior to a Criminal case assessment and progression panel (CCAPP) referral. This referral was made on 15/02/23. This case was accepted as a potential specific incident and assigned an

investigator from CQC’s national enforcement team; investigations are now complete, and it has been adjudged that CQC has no basis to take further action as there is insufficient evidence linking this directly to a registered person. The family were made aware of the outcome of CQC’s decision and CQC will continue to monitor the provider.

We are also pleased to read that Aria Care along with support from the CQC have moved to use lockable remotes on riser-recliner chairs and agree other actions to prevent a tragic event such as this happening again,

I hope this response is helpful. Thank you for bringing these concerns to my attention.

Helen Whately MP

Department of Health and Social Care Central Government

26 Apr 2024 PDF

Noted

The Department of Health and Social Care acknowledges the concerns, notes the CQC's investigation and outcome, and mentions Aria Care's move to use lockable remotes on riser-recliner chairs. (AI summary)

View full response

Dear Ms Samantha Marsh,

Thank you for your Regulation 28 report to prevent future deaths dated 31/10/2023 about the death of Evelyn Ann Burcham. I am replying as Minister with responsibility for adult social care.

Firstly, I would like to say how saddened I was to read of the circumstances of Ms Burcham’s death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for the delay in responding to this matter.

Your report raises concerns over electric riser-recline chairs which are commonplace in care home settings, including where residents suffer from cognitive impairment, and the risks of another resident with dementia accessing the controls of the chair(s). The report also raises concerns about the ability, or lack of ability, to ‘lock’ the remote control and/or find a safe way of storing it so that it is not accessible to anyone who does not have the authority, training or appropriate cognitive function to be able to use it safely.

In preparing this response, Departmental officials have made enquiries with NHS England and the Care Quality Commission (CQC).

The Department is content that the CQC have discussed the case internally on 06/01/23, including actions taken to date and proposed future actions. It was agreed that further information was required from the provider about the incident. CQC received the information requested and held further internal discussion on 13/02/23. CQC assessed that there was sufficient evidence to refer the incident to the Criminal Enforcement Support Hub (CESH) prior to a Criminal case assessment and progression panel (CCAPP) referral. This referral was made on 15/02/23. This case was accepted as a potential specific incident and assigned an

investigator from CQC’s national enforcement team; investigations are now complete, and it has been adjudged that CQC has no basis to take further action as there is insufficient evidence linking this directly to a registered person. The family were made aware of the outcome of CQC’s decision and CQC will continue to monitor the provider.

We are also pleased to read that Aria Care along with support from the CQC have moved to use lockable remotes on riser-recliner chairs and agree other actions to prevent a tragic event such as this happening again,

I hope this response is helpful. Thank you for bringing these concerns to my attention.

Helen Whately MP

Report sections

Investigation and inquest

On the 28th of December 2022 I commenced an investigation into the death of Evelyn Ann Burcham, aged 96. The investigation concluded at the end of the inquest on the 27th September 2023. The conclusion of the inquest was ‘Accidental Death’ with the medical cause of Mrs Burcham’s death being given as: Ia) Head Injury

Circumstances of the death

Mrs Burcham had resided at Frethey house Nursing Home (“the Home”) since May 2017. She had suffered a stroke in 2016 and her condition had progressively worsened due to dementia. Mrs Burcham was incapable of doing anything for herself and she relied on the staff at the Nursing Home to anticipate and meet her every need and provide her with full care, including; personal care, hoisting, transfer, nutrition etc. She also lacked capacity and could only communicate through incoherent mumbling and facial expressions, which the staff who knew her well at the home had learned to interpret. The Home is a residential and nursing home which, whilst accepting patients with dementia, is not a dementia specialist service. On the 14th of December 2022 the Home had organised a carol concert in the communal lounge as part of their Christmas celebrations. It was attended by residents and their families, staff and church volunteers. Mrs Burcham was brought to the lounge and hoisted into a standard riser-recliner chair. As she lacked any ability to support her own posture she was wedged in with pillows and the chair legs elevated by staff (via the remote control) to prevent her from slipping out. Carers then went to assist other residents to access the lounge ahead of the concert starting. The riser recliner chair that Mrs Burcham was in appeared to be a fairly standard design; an electric chair plugged in at the mains to enable the mechanism via a remote control, which is attached to the chair via a cord, with a side pocket for storage of the remote control whilst it is not in use. Whilst Mrs Burcham was in the riser-recliner chair unattended, another resident of the Home has accessed the remote control for the chair. This other resident had dementia which manifested itself in a compulsion to randomly fiddle. The other resident fiddled with the remote control buttons as they were accessible, unlocked and unsupervised and, without any intention or malice (or indeed any appreciation whatsoever of what she had done, because of her own cognitive impairment) managed to elevate the chair to its full rise position and tip Mrs Burcham onto the floor. Mrs Burcham had no power of speech to call for help, nor was she able to support her own weight or break her fall. She landed on her head and sustained a severe bleed on the brain, sadly dying of her injuries ten days later. 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 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. – I am concerned that these chairs are common place in care home settings where residents suffer from cognitive impairment. The risks of another resident with dementia accessing the controls of the riser-recliner chair(s) was not foreseen by the Home and so was not factored into any operative risk assessment at the time; hence no measures were in place to minimise the risk. There remains a real and immediate risk that those with a cognitive impairment that manifests itself in a compulsion to fiddle and/or press buttons, can create a risk of death to other residents in the same care facility or setting. If this particular care home group did not foresee the risk then it is likely that others have not foreseen it either.

Similar PFD reports

Shared signals

Related inquiry recommendations

Similar themes

Fuller Inquiry Care homes in scope for new regulatory regime

Coroner's concerns

Responses

Report sections

Similar PFD reports

Related inquiry recommendations

Report details

Responses identified

Sent to

Source links