Source · Prevention of Future Deaths

Emily Sims

Ref: 2019-0336 Date: 9 Oct 2019 Coroner: Guy Davies Area: Cornwall and the Isles of Scilly Responses identified: 1 / 1 View PDF

Care plans were not updated to reflect changing needs or multidisciplinary decisions. There was a lack of appropriate equipment, specialist advice, and staff training in equipment use and moving/handling.

Date 9 Oct 2019

56-day deadline 5 Jan 2020 est.

Responses identified 1 of 1

Care Home Health related deaths

Coroner's concerns

AI summary

View full coroner's concerns

1) The lack of updating of care plans to reflect changing needs and how to manage changing needs
2) The lack of updating of care plans to include reference to multi-disciplinary meetings or care needs meetings and decisions taken to manage changing needs
3) The lack of the provision of appropriate equipment such as adjustable beds to address changing needs
4) The lack of the provision, or access to, specialist advice from occupational therapists and physiotherapists to assist with measures to address changing needs
5) The lack of appropriate training regarding the use of equipment and moving and handling

Responses

1 respondent

Antron Manor Care Home Other

PDF

Action Taken

The care home implemented a new care plan template that includes a system for recording outcomes of meetings with professionals. Staff receive regular training and supervision, and a manual handling assessment is included in the new care plan. (AI summary)

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Dear Mr R Davies acknowledge receipt of your Regulation 28 Report in the case of Emily Sims respond to your numbered concerns as follows Lack of updaling of care plans t0 reflect changing needs and how t0 manage changing needs As understand care plans in place at the time of the incident were not updated or reviewed appropriately: Our current system consists of monthly review of care plans and amendments are made to reflect care needs and any changes necessary, permanent or temporary: Lack of updating of care plans to include reference to multi-dlisciplinary meelings Or care needs meelings and decisions taken to manage changing needs. The previous template used for care planning did not lend itself to recording of multi- disciplinary meetings with professionals and actions required t0 allow for changes t0 be recorded in the care plan: A new care plan template has been introduced t0 include a more robust system for recording outcomes of meetings with professionals, this inforation is then reviewed and the care plan is amended and updated according to changes in need. During our last inspection in November 2018, we had some old format care plans that were in the process of being changed over; all care plans have now been changed over to the new format with regular reviewing in place_ Lack of provision of appropriate equipment such as adjustable beds to address changing needs; requirement for equipment is addressed through assessment by occupational therapistsl physiotherapists, we have contact with the community rehabilitation team who all support and facilitate any provision for suitable equipment that is required to support individuals. Equipment is delivered to the home by Cornwall Council Loans Department: currently have 2 individuals with hospital beds, we also have other equipment to support individuals needs including perch stools, pressure cushions, cot sides, rails and walking aids. Lack of provision Or access t0 specialist advice from occupational therapisis and physio therapists l0 assist wilh measures to address changing needs. The home has good working relationships with the community rehab Team and Occupational Therapist: We access referrals for specialist advice through the GP practice and are very well supported by the district nursing team: Antron Manor Care Limited Company Number: 10516614 Directors Debbie Blight, Allan Blight and Rebecca Wood. Guy Guy Daisy Any We grab

ANTRON MANOR CARE HOME Antron Hill Mabe Burnthouse Penryn TRI 9HH Tel: 01326 367570 The Lack of appropriate training regarding use of equipment and moving and handling: At the time of the incident understand there was a lack of training: Training is scheduled regularly and monitored t0 ensure all staff members receive regular training: Supervision of all staff is carried out 6 times a year; where staff have opportunity to raise any concerns and discuss any additional training to support them. Our moving and handling training is carried out annually and all members 0f staff must attend. Our new care plan includes a manual handling assessment which provides staff with details on moving individuals safely. Summary We were not responsible for this service at the time of the incident_ understand changes were made prior to our ownership. Since our ownership we have continued to implement further changes to improve the service to ensure safety of the Residents continually work in partnership with professionals to address individuals needs and have implemented a new care plan format and system for the review and updating: Staff continue to receive regular training and supervision to ensure they are competent in their roles. We will continue to take every reasonable precaution t0 try to prevent any future incident.

Report sections

Investigation and inquest

On 16th November 2017 I commenced an investigation into the death of EMILY DAISY SIMS. The investigation concluded at the end of the inquest on 27th September 2019. The conclusion of the inquest was as follows:

The four questions - who, when, where and how – can (therefore) were answered as follows;-

Emily Daisy SIMS died on 1st November 2017 at Royal Cornwall Hospital Truro from trauma sustained as a consequence of the manner in which she was moved and manhandled out of bed, when in a frail condition.

My conclusion as to the death was as follows;-

Mrs Emily Sims died from a recognised complication of spiral fractures to her thighs sustained in an incident on Friday 27th October 2017 in which Mrs Sims was held by the ankles and swung out of bed by the night carer, applying torsion to the legs which caused the bilateral spiral femoral fractures. Whilst general frailty of health were likely to be co-factors, it is clear that the injury from the incident was the significant contributory factor which led to her death. The incident was contributed to by neglect, namely the manner in which she was moved and manhandled out of bed, when in a frail condition, by the night carer, which was more than likely to cause injury. Information Classification: CONTROLLED

The medical cause of death was established on the evidence as follows;-

1a Perforated duodenal ulcer in a frail, elderly female hospitalised with bilateral femoral fractures.

Circumstances of the death

At the time of her death 101-year-old Mrs Sims was a resident of the Antron Manor Care Home. There were no independent witnesses to the incident in which Mrs Sims sustained her injuries, bilateral spiral fractures to both femurs. Mrs Sims account (given to police before her death) was that she had been held by the ankles and swung out of bed by the healthcare worker. This caused her immediate and intense pain. The medical evidence established that this action would have the effect of applying torsion to the legs which caused the bilateral spiral femoral fractures. The stress of the fractures caused the ulcer which in turn caused the death of Mrs Sims.

Evidence established that the night carer was or ought to have been aware of the risk of injury from moving and handling an elderly resident such as Mrs Sims in this manner.

A review of the night carer’s training record by the police revealed that the night carer had not undertaken moving and handling training since 2012.

Care home staff gave evidence that they had not received training on the use equipment. Further that they had advised care home managers that Mrs Sims non-adjustable bed was, in their view, inappropriate for a resident in her frail condition.

A review of Mrs Sims care plan by an occupational therapist revealed the following:

1) No new care plan had been completed to reflect Emily’s changing needs.
2) There was no long-term plan to manage Emily’s changing needs
3) There was no documentation of objectives in the care plan
4) Entries by staff on the care plan do not appear to have resulted in any changes to reflect Mrs Sims’ changing needs and risks.
5) Mobilising equipment was incorrectly assembled.
6) Mrs Sims bed was non-adjustable and consideration should have been given to using an adjustable bed to diminish risks presented by the non-adjustable bed.

The court heard evidence from a CQC report of January 2019 that there remained an issue of staff updating care plans with changing needs. Information Classification: CONTROLLED

Inquest conclusion

The four questions - who, when, where and how – can (therefore) were answered as follows;-

Emily Daisy SIMS died on 1st November 2017 at Royal Cornwall Hospital Truro from trauma sustained as a consequence of the manner in which she was moved and manhandled out of bed, when in a frail condition.

My conclusion as to the death was as follows;-

Mrs Emily Sims died from a recognised complication of spiral fractures to her thighs sustained in an incident on Friday 27th October 2017 in which Mrs Sims was held by the ankles and swung out of bed by the night carer, applying torsion to the legs which caused the bilateral spiral femoral fractures. Whilst general frailty of health were likely to be co-factors, it is clear that the injury from the incident was the significant contributory factor which led to her death. The incident was contributed to by neglect, namely the manner in which she was moved and manhandled out of bed, when in a frail condition, by the night carer, which was more than likely to cause injury. Information Classification: CONTROLLED

The medical cause of death was established on the evidence as follows;-

1a Perforated duodenal ulcer in a frail, elderly female hospitalised with bilateral femoral fractures.

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Report details

Reference: 2019-0336
Date of report: 9 October 2019
Coroner: Guy Davies
Coroner area: Cornwall and the Isles of Scilly

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: 5 Jan 2020 (estimated).

Sent to

Antron Manor Care Home

Source links

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Data: judiciary.uk under OGL.