Source · Prevention of Future Deaths

Norman Baxter

Ref: 2020-0098 Date: 22 Apr 2020 Coroner: Chris Morris Area: Manchester South Responses identified: 1 / 1 View PDF

No specific concerns were detailed in the provided text for this report beyond a general statement of risk.

Date 22 Apr 2020

56-day deadline 16 Jun 2020

Responses identified 1 of 1

Care Home Health related deaths

Coroner's concerns

AI summary

No specific concerns were detailed in the provided text for this report beyond a general statement of risk.

Responses

1 respondent

Lynmere Nursing Home Other

PDF

Action Taken

Following the inquest, the nursing home implemented the News Scoring System, NEWS 2 Charts, Algorithm for managing suspected sepsis, and Sepsis guidance implementation advice. One-to-one discussions were held with nursing staff to confirm their understanding, and agency staff are also advised on the use of these tools. (AI summary)

View full response

Dear Mr Christopher Morris

I am in receipt of your email and Regulation 28 report.

I wish to advise that following the Inquest, a discussion between myself and

the previous manager took place and the following was put into place with immediate effect.

1. The News Scoring System
2. NEWS 2 Chart 1,2,3 (observation chart),and 4
3. Algorithm for managing suspected sepsis in adults and young people aged 18 years and over, outside an acute hospital setting. Sepsis risk stratisfication tool
4. Sepsis guidance implementation advice for adults

This was followed up by one to one discussions with all our Nursing staff confirming their understanding and how to use the tools.

the acting manager has also been made aware of the contents of the Regulation 28 report and I wish to confirm that these tools are being used and that any new nursing staff recruited since have also been made aware. Any agency staff that work at Lynmere are also advised of the use of these tools and their importance.

If I or my Manager, can be of any further assistance please do not hesitate to contact us.

Kind Regards

RMD Care Services Ltd t/a Lynmere Nursing Home

Report sections

Investigation and inquest

On 28th August 2019, Alison Mutch OBE, Senior Coroner for Manchester South, opened an inquest into the death of Norman Baxter, who died at Stepping Hill Hospital Stockport on 8th August 2019 aged 87 years. The coronial investigation concluded with the inquest which I heard on 18th and 21st February 2020. At inquest, it was determined Mr Baxter died as a consequence of
1) a) Severe sepsis and septic shock b) Infective exacerbation of Chronic Obstructive Pulmonary Disease and e-coli infection of unconfirmed origin. II) Type 2 diabetes, probable myeloma, previous hip fracture resulting in girdlestone procedure. The inquest concluded with a narrative conclusion, to the effect that Mr Baxter died as a consequence of complications of Chronic Obstructive Pulmonary Disease and an e-coli infection. Whilst this is a natural cause of death, it is likely his death was contributed to in part by a previous hip fracture sustained in hospital which ultimately required a girdlestone procedure.

Action should be taken

1. The court heard evidence that, at the time Mr Baxter was cared for at Lynmere, nursing observation charts were not in use. Nursing observation charts, when completed, may assist staff in appreciating an acute episode of illness, or deterioration in a resident’s condition. This may particularly be the case were the observation chart to be used in conjunction with a system such as NEWS2, an aggregate scoring system intended to standardise the assessment of, and response to, acute illness.

Copies sent to

law. the Care Quality Commission and Stockport MBC

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2020-0098
Date of report: 22 April 2020
Coroner: Chris Morris
Coroner area: Manchester South

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 16 Jun 2020.

Sent to

Lynmere Nursing home

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.