Source · Prevention of Future Deaths

Ann Stillwell

Ref: 2021-0091 Date: 8 Dec 2020 Coroner: Graeme Irvine Area: East London Responses identified: 2 / 2 View PDF

The Commissioner failed to authorise essential 1:1 care for a patient at high risk of falls, despite it being the only identified method to mitigate her specific risks.

Date 8 Dec 2020

56-day deadline 26 May 2021 est.

Responses identified 2 of 2

Care Home Health related deaths

Coroner's concerns

AI summary

The Commissioner failed to authorise essential 1:1 care for a patient at high risk of falls, despite it being the only identified method to mitigate her specific risks.

View full coroner's concerns

In the circumstances it is my statutory to report to you: _ Mrs Stillwell was at high risk of falls during the entirety of the period of 25th May 2020 until the 3rd July 2020. During that period the Commissioner for her care did not authorise 1:1 care. 1:1 care would have been the only way in which the particular risk presented by Mrs Stillwell to herself could have been mitigated.

Responses

2 respondents

Clinical Commissioning Group NHS / Health Body

8 Dec 2020 PDF

Action Taken

The Clinical Commissioning Group has already introduced changes to the process of requesting 1-to-1 care by care providers in November 2020, including routing requests to a senior nurse assessor for a response within 2 hours and requiring further evidence for extensions. They are also adding a safeguard to ensure that requests for 1 to 1s are submitted to the brokerage team and are escalated to a senior clinician, to be built into their electronic systems by the end of February 2021. (AI summary)

View full response

Dear Mr Irvine

Re: Inquest touching upon the death of Mrs Ann Doris Stillwell, Regulation 28

Report

I write in response to the Prevention of Future Deaths Report issued to Havering Clinical Commissioning Group on the 8 December 2020, following the Coroner’s inquest into the death of Mrs Ann Doris Stillwell.

The CCG director lead and head of service have met to discuss the Coroner’s concerns set out in the Regulation 28 report and agreed actions to strengthen the management of requests for 1 to 1 care by care providers.

Some changes to the process had been introduced in November 2020 which will reduce the risk of a similar incident occurring again and some additional actions have been agreed for implementation in February 2021.

Please find attached a report for the Coroner on the actions that have been taken.

The CCG strives to learn from incidents and to constantly improve the service provision it provides. Please do not hesitate to contact me if you require any clarification.

Thank you for your helpful insights into this case.

Dept of Health and Social Care Other

3 Mar 2021 PDF

Noted

The Department of Health and Social Care acknowledges the concerns raised and states that the CCGs are responsible for commissioning 1:1 care and have provided a response detailing actions taken. The Department will work with NHS England to consider the circumstances of the case but does not consider a change in national policy is required. (AI summary)

View full response

Dear Graeme,

Prevention of Future Deaths: Ann Doris Stillwell

Thank you for your letter of 8 December 2020 concerning the death of Ann Doris Stillwell, which came to the attention of the Department on 8 January 2021. I am responding as Minister with responsibility for continuing healthcare and I am grateful for the additional time in which to do so.

Firstly, I would like to offer my sincere condolences to Mrs Stillwell’s family. Ministers are committed to ensuring residents in care homes receive high quality and safe care. I am grateful that you have brought these matters in relation to Mrs Stillwell’s death to my attention.

As you are aware, the Department for Health and Social Care is responsible for Continuing Healthcare policy and in 2018, published the revised National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care1. The guidance sets out in paragraphs 165-180 where responsibility for care planning, commissioning services and case management lies. This includes that clinical commissioning groups (CCGs) should operate a person-centred approach to ensure a care package is tailored to meet the needs of the individual.

CCGs are responsible for the commissioning of 1:1 care within their local areas. I understand that Barking and Dagenham Havering, and Redbridge CCGs, have provided a joint response which sets out the actions taken to learn from the findings presented, following Mrs Stillwell’s death.

This action includes a requirement for requests for 1:1 care to be sent to the Head of Service and a senior nurse assessor who will provide a response to the request within two hours. The CCGs’ response also sets out further steps to escalate requests to appropriate clinician level staff, where required.

The Department has considered the concerns raised in your report and in this instance, we do not consider that a change in national policy is required. However, Departmental officials will work with NHS England, which is responsible for providing assurance on the actions of CCGs, to consider the specific circumstances of this case and whether further regional monitoring may be required.

I hope this response is helpful.

HELEN WHATELY

Report sections

Investigation and inquest

On the 7th July 2020 opened an investigation touching the death of Ann Doris Stillwell, aged 78 years old. opened an inquest on the 15th July 2020. The inquest concluded on the December 2020. The conclusion of the inquest was accidental death The medical cause of death was; Ia Pneumonia 1b Left Neck of Femur Fracture (operated) Frailty, Asthenia 'Care, Area 3rd

Circumstances of the death

On 22nd June 2020 Mrs Stillwell was discharged from hospital to a care home following the surgical repair of a broken right neck of femur sustained in a fall in a care home on 25th May 2020-Mrs Stillwell was at high risk of falls caused by a combination of factors; Mrs Stillwell's frailty, her dementia which limited her perception of risk, whilst at the same time made her forget her mobility restrictions and her independent and assertive nature_ Discharge notes recommended a high level of supervision, noting a significant history of falls, dementia, and mobility issues Following a pre-admission assessment; the care home manager asked the commissioner to authorise funding for 1:1 care, this was declined. On the morning of 3rd July 2020 Mrs Stillwell sustained a fall in her care home whilst subject t0 general observations_ No apparent injury was found. The care home manager renewed her application to commissioner for funding for 1:1 care On the afternoon of 3rd Mrs Stillwell sustained another fall and this time suffered a left-sided neck of femur fracture. Despite medical treatment she succumbed to complications of her injuries and died on Sth July 2020.

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action

Similar PFD reports

Shared signals

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Report details

Reference: 2021-0091
Date of report: 8 December 2020
Coroner: Graeme Irvine
Coroner area: East London

Responses identified

Responses identified 2 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 26 May 2021 (estimated).

Sent to

Department of Health and Social Care

Havering Clinical Commissioning Group

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.