Source · Prevention of Future Deaths

Andrew Hogg

Ref: 2019-0400-wp26913 Date: 27 Nov 2019 Coroner: Christopher Briggs Area: Manchester (South) Responses identified: 1 / 1 View PDF

A care home failed to adequately assess and manage escalating falls risks, lacking a comprehensive falls policy, proper risk reassessments, internal investigations, and proactive measures or equipment to prevent repeated incidents.

Date 27 Nov 2019

56-day deadline 22 Feb 2020 est.

Responses identified 1 of 1

Care Home Health related deaths

Coroner's concerns

AI summary

View full coroner's concerns

In the circumstances it is my statutory duty to report to heard evidence of the sequence of falls which have recounted above. While there may have been a falls assessment when Andrew first became resident at the home, there was no evidence before me of nature and extent of that assessment: More particularly there was no evidence of any steps taken to review or reassess the falls risk following the falls Andrew had commencing in January 2019. There were some 7 falls before final fall and it is a matter of concern that while each seems to have been dealt with reactively in that relevant assistance was sought; there were no steps considered to address what clearly was an escalating risk: In evidence heard froml Iwho was the manager of the home (although accept he was only recently in post). having given evidence as to the facts above accepted that insufficient measures were taken to address the risks which were evident: In particular he identified that: - Not all the relevant paperwork was completed following the falls There could have been engagement with other services such as the local falls clinic Consideration should have been given to using available equipment such as a sensor mat and "silent minder" Relevant information should have been updated onto the patient's electronic record. While welcome his insightful comments remain concerned that There was no adequate falls assessment policy There was no obvious escalation pathway following the sequential falls Andrew had There was no internal investigation into any of the falls which occurred There was no consideration of steps which could have been taken t0 reduce the risk, whether by way of equipment or increased or more direct carer supervision: bang May floor you: the his

It seems to me that each incident was dealt with reactively ad individually with no proactive consideration given steps which could be taken to reduce or ameliorate the risk of falling which quite obviously was increasing: While it cannot be said that had such steps been taken Andrew would not have fallen when he did, do think that the risk of that happening would have been substantially reduced:

Responses

1 respondent

Borough Care Ltd Local Authority / Fire Service

26 Nov 2019 PDF

Action Planned

• All home managers will review falls on the Person Centered Software (PCS) system weekly and add notes regarding actions taken to the falls log and residents' support plans. • For any resident with more than two falls within a two-week period, a review with their GP or CPN will be arranged. • Area Managers will review this process as part of their monthly audit. (AI summary)

View full response

Dear Mr Briggs Thankyou for your letter dated 26th November 2019 and the Regulation 28 served for my attention Please accept my apology for the delay in my reply due to my being on Jury Service, Illness and Christmas Holidays: [have investiagted your concerns and agree that each fall had been dealt with appropriately, buta review into the number of falls and the timescale in which the falls occurred did not appear to happen at that time In our other homes the falls would be reviewed at least monthly following the actioning ofthe SMBC Safeguarding Home managers would have escalated the level of falls to the GP or the falls clinic: feel that due to Mr Witon being a new manager this process was overlooked: He had only been with the business a matter ofa few weeks and was still working though his induction process: However; to tighten up our process all home managers will be reviewing falls on our PCS (Person Centered Software) system on a weekly basis to ensure that falls are monitored more frequenty: Managers will the falls log for the week and add notes as to what actions have been taken: These notes will also be added to the support plans of those residents involved: Collectively as a group of managers we have also agreed that any resident who has more than two falls within a two week period we will arrange a review with their GP or CPN. Borough Care Umilod T.0161 4750140 A: 9 Acom Businass Part E:anqulroseboroughcar arguk Heaton Lone. Slockpart SK4 1AS W: borughcoraorguk Letcurtd mbeutbeder Sdelveth coedt ran AetcaOma Anb i PeL HedmL Re57ILIAOAHmn JTA AG JAN _ HM 72020 MANCHESTER: CORONER SOUTH Hogg log: print

This process will be reviewed by our Area Managers as part oftheir monthly audit To aid managers to complete this task weekly [ have added this action to our managers strategic calendar which prompts them daily, weekly monthy etc to actions required hope thatyou feel that we have taken promptactions and reviewed our practise to your satisfaction: Please feel free to contact me ifyou require any further information

Report sections

Investigation and inquest

On 16th May 2019 an inquest was opened into the death of Andrew Richard Hogg; who died at the Stepping Hill Hospital on 6uh 2019 aged 66 years. The investigation concluded at the end of the inquest which heard on 22nd October 2019. At the end of the inquest recorded that Andrew Hogg died as a result ofan accident; namely a fall he had on 3 May 2019 while at the Meadway Court Care Home, Meadway; Bramhall; Stockport SK7 1Z as a result of which he suffered a head injury which led to a subdural haematoma from which he did not recover

Circumstances of the death

Andrew Hogg began to have difficulties coping and was referred to adult social services in 2017 . Efforts were made to assist him in the community but increasingly he was unable to cope due to his underlying Parkinson'$ disease and possible dementia. He therefore moved into the Meadway Court Care Home on 20 April 2018 where he was resident until his death: Andrew had a history of falls and mobilised with a stick, although sometimes without it which increased his risk of falling: heard evidence that staff were aware of his risk of falling but it was not clear what if falls assessment had been undertaken: was told that consideration was given to placing a falls mat beside Andrew' s bed in December 2018 but he declined this thinking it would be a trip hazard_ Andrew then had a series of falls as follows:- 16.1.19 fall in lounge cut forehead paramedics attended 23.2.19 unwitnessed fall in bedroom cut on elbow 14.3.19 unwitnessed fall in lounge paramedics attended 30.3.19 unwitnessed fall in bedroom 24.4.19 - witnessed fall in lounge area to forehead Paramedics attended May any cut

25.4.19 fall in downstairs lounge to head and lump on shoulder paramedics contacted however out of hours GP attended 26.4.19 - unwitnessed fall in bedroom telephone advice from out of hours GP. On 1.5.19 the lump on the shoulder and bruising were more noticeable and Andrew was taken to hospital where a fractured clavicle was diagnosed. This was treated with support and he was discharged back to the Home on 2.5.19 Upon his return staff recognised Andrew was at high risk of falls and it was planned that Andrew should not walk alone and mobilization should be by wheelchair with one carer at all times. On 3 2019 Andrew was found on the of his room. An ambulance was called and he was admitted to Stepping Hill Hospital where CT scan revealed a large subdural haematoma. Following discussion with the neurosurgical team in Salford Royal Hospital it was concluded that Andrew would be unlikely to survive any operative intervention and palliative care was given until his death on 6 May 2019.

Action should be taken

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

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2019-0400-wp26913
Date of report: 27 November 2019
Coroner: Christopher Briggs
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: 22 Feb 2020 (estimated).

Sent to

Borough Care Limited

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.