Source · Prevention of Future Deaths

Irene Collins

Ref: 2019-0306 Date: 19 Sep 2019 Coroner: Chris Morris Area: Manchester (South) Responses identified: 0 / 1 View PDF

Unrestricted access and disposal of clinical examination gloves in care settings pose a risk, particularly for residents with cognitive impairment who can easily access them.

Date 19 Sep 2019
56-day deadline 31 Dec 2019 est.
Responses identified 0 of 1
Care Home Health related deaths

Coroner's concerns

AI summary
Unrestricted access and disposal of clinical examination gloves in care settings pose a risk, particularly for residents with cognitive impairment who can easily access them.
View full coroner's concerns
In the circumstances it is my statutory to report to you: The court heard evidence that at Firbank House, there was unrestricted access t0 clinical examination gloves and other personal protective equipment intended to be used by those delivering care from wall-mounted dispensers in corridors. Additionally, at that time; once used the clinical examination gloves could be disposed of in a variety of bins, which were again easily accessible to residents_ Whilst significant steps have now been undertaken at Firbank House t0 restrict the access of clinical examination gloves to residents with cognitive impairment; it is a matter of concern that in many settings where care is provided to vulnerable people, they are extremely easy to access. It is considered an alert or authoritative guidance as to the storage and disposal of clinical examination gloves in care settings may prevent future deaths.

Report sections

Investigation and inquest
On 7th November 2018,an inquest was opened into the death of Irene Collins who died on 16th June 2018 at Firbank House Residential Home, Ashton-under-Lyne aged 78 years The investigation concluded with an inquest which heard between 22nd.24th July 2019 and which concluded with a Narrative Conclusion to the effect that Mrs Collins died as a consequence of obtaining and ingesting a latex glove whilst unsupervised at her care home_
Circumstances of the death
Mrs Collins was formally diagnosed with dementia in 2015. Following the sudden death of her husband in 2017, she was assessed as requiring full-time residential care and after a brief period in another establishment; moved into Firbank House Residential Home_ Bv this time Mrs Collins' health problems had become complex and significant ad included Type 2 Diabetes, Chronic Obstructive Pulmonary Disease, low mood, Ischaemic Heart Disease, Chronic Kidney Disease stage 3 and macular degeneration, in addition to dementia. Over the final months of Mrs Collins' life, her dementia became advanced and she developed an appreciable propensity to insert foreign objects into her mouth: On 16th June 2018, Mrs Collins was found dead in a chair in the communal lounge of the care home_ At post mortem examination, a pathologist acting on behalf of the coroner found a latex clinical examination glove in Mrs Collins' proximal trachea 'larynx: The examination was stopped and a forensic post mortem examination then took place. The conclusion of the Home Office pathologist was that Mrs Collins died as a consequence of:- 1a) Upper airway obstruction;
2) Multi-infarct dementia
Action should be taken
In my opinion action should be taken to prevent future deaths and believe vou and vour organisation have the power to take such action:

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Report details

Reference
2019-0306
Date of report
19 September 2019
Coroner
Chris Morris
Coroner area
Manchester (South)

Responses identified

Responses identified 0 of 1
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 31 Dec 2019 (estimated).

Sent to

MHPRA

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