Source · Prevention of Future Deaths

Douglas Minns

Ref: 2019-0052 Date: 14 Feb 2019 Coroner: Tom Osborne Area: Milton Keynes Responses identified: 1 / 1 View PDF

The coroner raises concerns about the withdrawal of a falls service, which provided home visits to assist those who had fallen, assessing that this puts patients' lives at risk and suggests re-introducing the service due to strains on the ambulance service.

Date 14 Feb 2019

56-day deadline 4 Apr 2019

Responses identified 1 of 1

Emergency services related deaths (2019 onwards)

Coroner's concerns

AI summary

View full coroner's concerns

The MATTERS OF CONCERNS are as follows: During the course of the evidence it was explained to me that the provision of a falls service was withdrawn some years ago, the service would provide for someone to attend the home of the person who had fallen, get them on their feet, assess their wellbeing, serve a cup of tea and get them back into bed if required. If they required more urgent treatment, they would report to the ambulance service. The withdrawal of the service puts patient’s lives at risk and, in view of the strains on the ambulance service, consideration should be given to re-introducing it. It is unacceptable for a 93 year old man to be left lying on the floor for four hours before someone responds.

Responses

1 respondent

Milton Keynes Clinical Commissioning Group NHS / Health Body

28 Mar 2019 PDF

Noted

Milton Keynes CCG describes community-based services that superseded a previous falls service, including a Home 1st Rapids service and the Staying Steady service, and asserts that these meet the original service's objectives. (AI summary)

View full response

Dear Ms Toms Re: Regulation 28 Report to Prevent Deaths: Falls service Thank you for your letter received 18h February, concerning the fall and subsequent death of Mr M. Milton Keynes did have a falls service as you describe, some years ago. That service was superseded by a number of community based services that have been put in place to offer a targeted approach to individual situations. These include: A Home 1" Rapids service provided by our community provider, CNWL comprising of experienced nurse practitioners and prescribers, who respond to a call from a GP, ambulance services or other allied health professional. The service triages all calls within 15 minutes and has a 2 hour attendance requirement, unless advised otherwise by another health care professional who has seen the patient In the majority of cases, attendance by Home 1st Rapids will result in the patient assessed and made comfortable at home, avoiding a hospital attendance. Should transfer to hospital be necessary, the team calls for assistance or an ambulance according to the severity of the condition_ This service operates 24/7 , has approximately 1500 new referrals per year and is provided in people's homes including Care Homes: The Staying Steady service provided by CNWL therapists as part of their Home 1* function. It is intended for people usually over 65 who or are at risk of falling: The service works with individuals t0 improving balance, core strength, mobility etc. It is not an acute service, but takes referrals form GPs, hospital staff or selflrelatives. The service assesses an individual's fall risk factors and works with them t0 make changes in their home environment where necessary, including providing adaptive equipment: also investigate the circumstances surrounding a fall and develop a preventative action plan to increase confidence with walking and daily activities; as well a8 developing individual exercise programmes that they be undertaken at home to develop strength and balance This service, operating in office hours, receives approximately 1600 referrals a year: being have, They

The MK Councils Falls Service provided by B-Well works with Staying Steady to provide assessment; treatment and advice to older people who have fallen, are at risk of falling, or are fearful of falling; in a supportive environment; People can be assessed in their own homes and where exercise classes are required these are available free of charge to help reduce the risk of falling and improve mobility and balance hope the above description of commissioned services provides suitable assurance that although the original falls services was discontinued, it has been replaced by a 24/7 Home 1st Rapids service to deal with acute episodes of falling in community; supported by two in office hours services which focus on prevention and non-urgent needs. The Home 1* Rapids service reflects the objectives of the Original falls service in that they attend the home, carry out an assessment, make the individual comfortable and call an ambulance if required; Please do not contact me should you require additional information

Report sections

Investigation and inquest

On 23/08/2018 I commenced an investigation into the death of Douglas Albert Walter MINNS aged
93. The investigation concluded at the end of the inquest on 17th December 2018. The conclusion of the inquest was that the deceased died from an accident, namely the fall at home.

Circumstances of the death

The deceased suffered a fall at home, , on 21st August 2018 at 8.30pm in the evening and he made an emergency call to the ambulance service. He was attended to by the ambulance service at 00.25 on 22nd August 2018 and he was eventually conveyed to Milton Keynes University Hospital arriving at 02.08. A CT scan revealed a large subarachnoid and subdural bleed caused by the fall. He died at the hospital at 15.50 on 22nd August 2018. The delay in the ambulance attending was due to high operational demand.

Action should be taken

7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 4th April 2019. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons

South Central Ambulance Service The Family of Mr Minns I have also sent it to the Chief Executive of Milton Keynes Hospital who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. Tom OSBORNE Senior Coroner for Milton Keynes Dated: 14 February 2019

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Report details

Reference: 2019-0052
Date of report: 14 February 2019
Coroner: Tom Osborne
Coroner area: Milton Keynes

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: 4 Apr 2019.

Sent to

Milton Keynes Clinical Commissioning Group

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.