Source · Prevention of Future Deaths

Margaret Melia

Ref: 2019-0320 Date: 18 Apr 2019 Coroner: Zafar Siddique Area: Black Country Responses identified: 1 / 4 View PDF

The report cites inadequate discharge and pre-assessment processes between Lakeview Care Home and Dovetail Care Home regarding the requirement of subcutaneous fluids.

Date 18 Apr 2019
56-day deadline 13 Jun 2019
Responses identified 1 of 4
Care Home Health related deaths

Coroner's concerns

AI summary
The report cites inadequate discharge and pre-assessment processes between Lakeview Care Home and Dovetail Care Home regarding the requirement of subcutaneous fluids.
View full coroner's concerns
1. Evidence emerged during the inquest that there was an inadequate discharge and pre-assessment process between Lakeview Care Home and Dovetail Care Home over the requirement of subcutaneous fluids.

Responses

1 respondent
HC One Other
13 Jun 2019 PDF
Action Taken

HC-One reviewed and updated their Admission, Transfer and Discharge Procedure to include clearer guidance for colleagues when a delay occurs between the pre-admission assessment and admission, ensuring further information is sought if the pre-assessment was completed more than five days prior to admission, and updated the Admission process checklist to reflect this improvement in practice. (AI summary)

View full response
Dear Mr Siddique,

I write to inform you of the actions taken at HC-One in response to your Regulation 28 report to prevent future deaths, following your investigation into the death of Mrs Melia.

In response to the matters of concern highlighted, we took the following actions:

We reviewed our policies and practices as an organisation in relation to our pre-admission and admission processes.

We reviewed the current Admission process checklist.

The action we have taken as a result:

On reviewing our practices, we identified that if a delay occurred between the pre-admission assessment conducted, there needed to be clearer guidance set out for colleagues within our Admission, Transfer and Discharge Procedure (Appendix 1). We have now included practice that in the eventuality the pre-assessment was completed more than five days prior to admission to the home, further information should be sought from the hospital ward/care home/social worker as soon as possible. This will include the update of any medication changes or outcome of any recent healthcare professional reviews of the person during this period, to avoid any misunderstanding that could result in harm.

The changes to practice have been cascaded across the organisation via our Homes’ Bulletin, which is sent to our homes.

Our Admission process checklist (Appendix 2), which is available within all our homes to ensure all aspects of the organisation’s pre-admission and admission processes are completed, has been updated to reflect this improvement in practice.

I do hope this information is helpful and offers you the reassurance that we, at HC-One, have taken the issues raised seriously and have taken appropriate action with the intention of improving the care and safety of our Residents.

Report sections

Investigation and inquest
On the 16 November 2018, I commenced an investigation into the death of Mrs Margaret Melia. The investigation concluded at the end of the inquest on 1 April 2019. The conclusion of the inquest was a short form conclusion of natural causes.

The cause of death was:

1a Advanced Dementia b c II Old Age, Malnourished, Ischaemic Heart Disease
Circumstances of the death
i) Mrs Melia was admitted to Dovetail Court Care Home on the 9 October 2018 from Lakeview Care Home. She had a medical history including arthritis, Alzheimer’s, chronic obstructive pulmonary disease and required substantial care for her daily living activities. ii) As part of the pre-assessment, on the 29 September 2018, Mrs Melia was assessed by a manager from Dovedale Court. The nurse on duty (Lakeview Care Home) advised the assessor that she would be requesting the GP to visit her in 2 days (01.10.18) to prescribe subcutaneous fluids due to Mrs Melia’s oral intake was poor and it would be required if her fluid intake dropped below 500ml daily. iii) The relevant equipment required to administer subcutaneous fluids wasn’t available at Dovetail Care Home and no subcutaneous fluids were given. iv) Mrs Melia’s condition started to decline rapidly from around the 22 October

[IL1: PROTECT] and her food and fluid intake dropped. v) She was admitted to Sandwell Hospital and treated for dehydration and a lower respiratory tract infection with antibiotics. Sadly, her condition continued to decline and she was placed on end of life palliative care. She passed away on the 7 November 2018.
Action should be taken
1. Both Care Homes may wish to consider urgently reviewing the protocols in place during discharge and pre-assessment of patients. In particular, the requirement of any medication should be set out clearly to avoid any misunderstanding that could result in harm to a patient.

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Report details

Reference
2019-0320
Date of report
18 April 2019
Coroner
Zafar Siddique
Coroner area
Black Country

Responses identified

Responses identified 1 of 4
3 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 13 Jun 2019.

Sent to

Care Quality Commission
Dovetail Court Care Home
HC-One
Lakeview Care Home

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