Cedric Skyers

Coroner's concerns

AI summary

The care home's smoking risk assessment for immobile residents fails to adequately address immobility risks, lacks clear guidance on safety equipment provision, and does not document refusal of professional advice.

View full coroner's concerns

The MATTER OF CONCERN is as follows. The management of the Care Home and its owners, BUPA, have undertaken a through investigation and implemented a detailed Action Plan which has reduced many of the risks to life of accidental fires from resident's smoking identified in the inquest. But one area remains a concern. BUPAcorporate guidance indicated, at the time of Mr Skyer's death and now, that residents who wish to smoke must have risk assessments with their abilities, dependencies and special requirements taken into account. The concern relates to the process of mitigating the risks from personal risk assessment of immobile patients. A new safe smoking risk assessment form has been introduced, which requires assessment of safely lighting and smoking a cigarette now to be recorded. The only new question to be asked which would score a concern for a resident such as Mr Skyers, in a wheelchair, is one as to whether the resident has any difficulty in balance. If that is recorded as yes, the process requires the documentation of the steps to be taken to limit associated risks. Nowhere is the risk associated with immobility specifically recognised, yet patients who are immobile and smoke in bed are required to be supervised. A BUPA Fire Risk Advisor told the court that he would recommend the same requirement should be made for those who are immobile but smoking elsewhere. The present policy appears to leave the nurse with the discretion as to what may be inserted into the plan. A BUPA manager informed the court that residents would be offered an apron and alarm pendant. This was not apparent in the documentation. It was not documented that a person who declined these would be expected to accept supervision, nor the importance of these for someone who is completely immobile. If this too was declined, it would seem that if the resident insisted in continuing to smoke without supervision or apron, consideration should be given as to whether this should be recorded as being a choice against professional advice. Reviewing all the evidence, including the variation in skills of nurses in smoking risk assessment and particularly noting the fire investigator's evidence that the resident's clothes can be completely consumed by fire in two minutes, the mitigation of risks of death to those who smoke outside in BUPA homes and are immobile and cannot summon help seem to have not been sufficiently recognised.

Responses

3 respondents

Lewisham Safeguarding Adults Board

22 Jun 2017 PDF

Action Planned

Lewisham Safeguarding Adults Board commissioned a Safeguarding Adult Review in April 2016 with revised terms of reference and an expected conclusion in July 2017; the Board's annual report for 2017/2018 will contain full details of lessons learned and an action plan, and learning seminars will be held. (AI summary)

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Dear Mr Harris Re Cedric Skyers (00725/2016) Regulation 28 report to prevent future deaths I refer to your letter dated 26th April 2017 in which you enclosed the report of your investigation and findings relating to the death of Cedric Skyers. I can confirm that a decision was taken by Lewisham Safeguarding Adults Board to commission a Safeguarding Adult Review in April 2016. Upon the appointment of a new Independent Chair for the Lewisham Safeguarding Adults Board in December 2016, the terms of reference for the Safeguarding Adult Review were reviewed and revised, progress on the collection and analysis of information was reviewed also and a new overview report writer was appointed. The terms of reference for the Safeguarding Adult Review are as follows: Safeguarding Adult Review into the death of Mr CS Terms of Reference (revised 3rd May 2017) Introduction
1. The Lewisham Safeguarding Adults Board (LSAB) has determined that the death of Mr CS satisfies the Care Act 2014 (Section 44) statutory requirement for a Safeguarding Adult Review (SAR). The LSAB has decided that an overview model, which documents events and analyses their causes, is appropriate in the circumstances; thereby satisfying the statutory guidance that the approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined. Scope of the SAR
2. It has therefore been determined that an independent overview author be appointed to:
a. Document and examine the events leading up to the fire on Sunday 13th March 2016
b. Review the original reasons for and suitability of Mr CS’s placement and the outcomes of subsequent placement reviews

c. Review Manley Court care plans and risk assessments relating to Mr CS; examining whether Mr CS was subject to any Mental Capacity Assessments, and the outcome of these; and any Physical Ability Assessments that were carried out
d. Examine the standards of practice within Manley Court Nursing Centre managed by The British United Provident Association Limited (BUPA)
e. Consider whether these comply with BUPA-wide and/or local policies, procedures and guidance with particular attention given to care planning and risk assessment as well as smoking – residents, staff, visitors and contractors
f. Evaluate whether these meet statutory and/or regulatory requirements and guidance (e.g. Health & Safety, Fire Safety, the Mental Capacity Act, and National Patient Safety Alerts etc.). Methodology
3. The independent overview author will work with a panel of the SAB to:
a. Prepare a composite headline chronology
b. Consider the review and learning of individual agencies since the incident and focus on good practice, identify aspects for further improvement and areas where multi-agency action is required
c. Undertake an analysis of causes and remedial actions recommended at professional, individual agency and across the multi-agency safeguarding system
d. The SAR investigation will seek to avoid duplicating the work of investigations by other authorities (the Coroner, the London Fire Brigade, the Metropolitan Police Service and Care Quality Commission) but rather draw on these for information and advice as well as providing an opportunity to pull together the findings of them all and explore any gaps
4. In terms of specific methodology the independent over view report has been asked to:
a. Utilise where beneficial the NHS Root Cause Analysis (RCA) Tool1 as the model is tried and tested in healthcare. (https://www.england.nhs.uk/patientsafety/root-cause/#). It has features which assist identify multiple causes and/or contributory factors focusing on those with the greatest potential to cause (and therefore prevent) future incidents.
5. It is expected that the SAR will:
a. Identify and summarise relevant data (e.g. documents, interviews, records, logs etc.)
b. Invite individual agencies to undertake their own analysis and then be a position to consider these in the round
c. Describe the chronology of events
d. Carry out an overview analysis to identify contributory factors (here it may be possible to utilise the National Patient Safety Agency Contributory Factor Classification Framework, see Appendix 1)
e. Order contributory factors by importance/impact
f. Identify policy, procedure and practices that may require improvement and recommend how and who needs to act and with what urgency.
6. The approach and methodology are intended to identify themes, solutions and achievable recommendations which could prevent similar occurrences and facilitate learning both specific to the incident and more broadly from the latter life and subsequent death of Mr CS. The purpose of the Safeguarding Adult Review is to learn lessons and, through their implementation, to seek to eliminate or reduce the risk of future deaths created by the circumstances that led to Cedric Skyers’ loss of life. It is planned that a draft report will be considered by the case review group of the Lewisham Safeguarding Adults Board at its June meeting and a timeframe for expected conclusion of the review process has been set for the end of July 2017. As required by the Care Act 2014 statutory guidance, the Board’s annual report for 2017/2018 will contain full details of the lessons learned and of the action plan that the Board will put in place.

Learning and service development seminars will also be held, and a briefing note produced and circulated, to ensure that the lessons learned through the review lead to service, policy and practice transformation where appropriate. If you wish to receive a copy of the final report of this Safeguarding Adult Review, please write to me to that effect.

CQC Regulator / Inspectorate

3 Jul 2017 PDF

Action Planned

The CQC is assisting the Fire Authority with a joint investigation and is planning to undertake a further unannounced comprehensive inspection of Manley Court in July 2017 to review documentation and consider whether the steps taken by the provider further reduce the risk to people at the service. (AI summary)

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Dear HM Coroner,

Response to Regulation 28 Report to Prevent Future Deaths Re: Cedrick Skyers, Ref. 00725-16

Thank you for sending the Care Quality Commission (CQC) a copy of the Regulation 28 Report to Prevent Future Deaths which we received on 10 May 2017 following the death of Mr Skyers, who lived at Manley Court Care Home. We are writing to you with our response to the issues raised within your report.

As you are aware, CQC is currently assisting the Fire Authority with a joint investigation to consider what (if any) criminal enforcement action may be appropriate against the registered provider specifically in relation to the death of Mr Skyers.

We note that you have the authority to publish this response. However, we respectfully ask that whilst the Fire Authority and CQC are considering their respective positions in relation to potential enforcement action that no publication of this letter takes place and that the letter is not provided to any other Interested Person(s).

Manley Court Care Home is based in New Cross in London and is registered to provide personal and nursing care for up to 85 older people. Prior to Mr Skyers’ death, CQC had inspected the service on 16 and 17 April 2015 and rated it “Requires Improvement” overall. There was one breach found in relation to staffing levels and the service was issued with a requirement notice. In addition, recommendations were made in relation to supporting staff and storing medicines at the correct temperature. You can find a copy of our report on our website

HSCA Further Information Citygate Gallowgate Newcastle upon Tyne NE1 4PA

2

Prior to the receipt of your report, the CQC became aware of Mr Skyers death via Mr Skyers’ son, who told us of his father’s death on 14th March 2016. We were informed that on 13 March 2016 Mr Skyers was smoking unattended in the garden of Manley Court when a staff member saw that he had caught alight and alerted other staff who put the flames out and contacted emergency services. Mr Skyers was attended to by paramedics but sadly died later that day at Kings College Hospital.

On the basis of the information received at the time, we carried out a comprehensive inspection following the incident on the 18th and 23rd of March
2016. We found concerns with risk assessments and staffing shortages. Our report is published on our website with a rating of Requires Improvement overall. You can find a copy of our report on our website http://www.cqc.org.uk/location/1- 127818698/reports.

The matters of concern raised in your report relate to the registered provider, Bupa Care Homes (ANS) Limited (“BUPA”), and their corporate guidance at the time of the incident giving rise to My Skyers death. We have raised similar concerns about the policy and guidance with BUPA in a written interview under caution document 17 March 2017 and a response from BUPA has been received in writing 14 April 2017. The CQC’s PACE questions of concern and related responses are likely to form exhibit evidence in any future possible criminal case.

CQC contacted BUPA on 31st May 2017 to request written confirmation and evidence of the action they had taken following Mr Skyers’ death and any additional action they intend to take in response to the prevention of future death report. We received a copy of their Root Cause Analysis Report and the consequent action plan. We acknowledge that Bupa have taken a number of actions to reduce the risk and are reassured by the steps taken so far.

Further to our request, BUPA wrote to inform us that, in the light of your Regulation 28 Report, they are undertaking a further review of smoking risk assessment documentation across all of their care homes. They have stated that the revised process includes an increased emphasis on the use of smoking aprons and supervision. The risk of fire will be explicitly discussed with residents and a refusal by any resident to wear a smoking apron will result in a more comprehensive risk assessment, including consideration of their mobility.

We are planning to undertake a further unannounced comprehensive inspection of Manley Court in July 2017 and will review the documentation and consider whether these steps further reduce the risk to people at the service. Again we would ask that this information not be passed onto any other Interested Person(s).

3

BUPA do acknowledge that a provider should not override a capable individual’s right to make unwise decisions. Following our request, they have written to us to inform us that if a resident who has capacity insists on smoking without supervision or a smoking apron, this will be permitted wherever possible, but will be recorded as being a choice against professional advice. We understand that the smoking risk assessment documents are at the final stages of production and will be shared with you and CQC by the Provider no later than 3 July 2017. Should you require any further information, please do not hesitate to contact me.

BUPA Other

3 Jul 2017 PDF

Action Taken

BUPA has revised its safe smoking assessment and smoking policy, including offering smoking aprons and pendant alarms to residents who smoke in the garden, and requiring supervision for those who decline to wear aprons or have fire-retardant clothing. The updated policy removes staff discretion in risk assessments and requires documentation of residents' choices against professional advice. (AI summary)

View full response

Dear Mr Harris

Regulation 28 report to prevent future deaths Mr Cedrick Skyers

I refer to the prevention of future deaths report touching the death of Cedrick Skyers, which was sent to Bupa and addressed to Evelyn Bourke. As the General Manager of Bupa Care Services UK, I provide this response on behalf of Bupa.

It was heard at the inquest that, following Mr Skyers’ tragic death, Bupa carried out a thorough investigation. This investigation revealed a number of actions which were required to be taken to reduce the risk of a similar incident occurring. All of these actions have now been completed and the updated action plan was included within the inquest bundle.

Those actions included a review of the smoking risk assessment form used across all Bupa homes, which was considered by HM Coroner at the inquest. We note that there were some remaining concerns about whether residents were offered smoking aprons and pendant alarms, as this was not evident from the documentation.

In light of the prevention of future deaths report, Bupa has undertaken a further review of the smoking risk assessment documentation and process used throughout our care homes. I attach, for your information, the revised Bupa Care Services Safe Smoking Assessment document. The updated process puts an increased emphasis on the use of smoking aprons and supervision. You will note that the document requires staff to offer all residents a smoking apron and encourage them to wear it when smoking. It further takes staff through a process of considering the capability of an individual resident to smoke, and removes a significant amount of discretion which was previously available to staff completing the risk assessment. In particular, please note that residents who smoke in the garden will be issued with a pendant alarm (2.2), and that those who decline to wear a smoking apron or have fire retardant clothing should be supervised (6.1).

All safe smoking assessments must be carried out by reference to the updated Bupa Smoking Policy BFM 20, a copy of which is also enclosed with this response.

HM Coroner recognised that a provider should not override a capable individual’s right to make unwise decisions, and therefore if a resident insists on smoking without supervision or a smoking

Bupa Care Homes (ANS) Limited No. 1960990 Bupa Care Homes (AKW) Limited No. 4122364 Bupa Care Homes (Bedfordshire) Limited No. 3333791 Bupa Care Homes (BNH) Limited No. 2079932 Bupa Care Homes (CFCHomes) Limited No. 2006738 Bupa Care Homes (CFHCare) Limited No. 2741070 Bupa Care Homes (GL) Limited No. 1587972 Bupa Care Homes (Partnerships) Limited No. 2216429 Registered in England and Wales. Registered Office: Bridge House, Outwood Lane, Horsforth, Leeds LS18 4UP Bupa Care Homes (Carrick) Limited No. SC151487. Registered Office: 39 Victoria Road, Glasgow G78 1NQ VAT Registration No. 239731641 apron, this will be permitted wherever possible but will be recorded as being a choice against professional advice.

I trust this response, and the attached Safe Smoking Assessment and Smoking Policy, alleviate your concern raised in the prevention of future death report, insofar as that concern relates specifically to Bupa care homes. However, should you require any further information, please do not hesitate to contact me.

Report sections

Investigation and inquest

I opened an investigation into this death on 31.03.16. The London Fire Brigade, Care Quality Commission and Metropolitan Police and Adult Safeguarding Board began investigations into this unnatural death in a nursing home. Delay to the coronial investigation was occasioned by the need for these authorities and the coroner to agree that there was no legal reason that the inquest could not be heard prior to any prosecution. I concluded an inquest on 16.10.17 with a narrative. CIRCUMSTANCES OF THE DEATH Mr Skyers was a hemiplegic resident of Manley Court Nursing Home, who could not stand or reposition himself on his own, nor propel his wheelchair. He was wheeled into the garden to smoke, a regular routine, on the morning of 13'h March 2016. He was assessed as safe to smoke on his own, but the staff were unaware that some of his laundered clothes had burn marks. He was known not to like supervision. He was unusually left alone in the garden and it was not evident how he could summon help. At about midday, he was seen to be on fire and immediate attempts were made to extinguish the fire by smothering and water, which was effective. It lasted less than five minutes. It had been caused by the breeze fanning his smouldering clothes, burnt by his lit cigarette. Emergency services attended promptly and despite full resuscitation he died at 13.05 in hospital of extensive burning. Had he been supervised or had means of alarm call, he would likely have survived.

Although not recorded, as evidence from the nursing home on the wearing of smoke aprons was not heard, Fire expert advice was accepted that had he been wearing a smoking apron, he would also have survived.

Action should be taken

I consider the evidence given at this inquest gives rise to a concern that circumstances creating a risk of other deaths will occur and in my opinion, action should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances. I am therefore reporting this matter to those who manage and regulate such nursing homes and to those who are investigating the circumstances of this death from the viewpoint of the needs of vulnerable adults.

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, the Metropolitan Police and the Secretary of State for Health and Social Services

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