Source · Prevention of Future Deaths

Kathleen Smith

Ref: 2017-0397 Date: 14 Nov 2017 Coroner: Chris Morris Area: Manchester (South) 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner noted that Mrs Smith's family and the care provider's corporate risk function were not informed of her hip fracture's details, limiting investigation and learning. There was no audit of incidents following the departure of the manager responsible for internal reporting, despite documentation allegedly going missing.

Date 14 Nov 2017

56-day deadline 12 Apr 2018 est. estimated from the Judiciary.uk publication date

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

The coroner noted that Mrs Smith's family and the care provider's corporate risk function were not informed of her hip fracture's details, limiting investigation and learning. There was no audit of incidents following the departure of the manager responsible for internal reporting, despite documentation allegedly going missing.

View full coroner's concerns

_ In the course of the inquest heard evidence that; whilst the management team at Lisburne Court had notified Greater Manchester Police and Stockport Metropolitan Borough Council of the incident in which Mrs Smith sustained on April 2017, neither the family nor Borough Care'$ corporate risk function had been notified of the circumstances which led to Mrs Smith's hip fracture This latter point raises a particular concern a5 to Borough Care'5 ability to undertake any meaningful investigation into the circumstances of Mrs Smith'$ injury, with a view to deriving learning for the benefit of other residents. The inquest also heard evidence that Lisburne Court's process for internal incident reporting and escalation largely fell to an individual manager who has since left Borough Care'$ employment: It was a matter of concern that notwithstanding this fact, no audit or similar review exercise as to incidents or issues at Lisburne Court had been undertaken since the departure of the individual manager in question, despite the evidence of the Interim Head of Care that some resident documentation and computer files has allegedly gone missing:

Responses

1 respondent

Borough Care

Local Authority

Letter dated 28 Nov 2017 PDF

AI-classified response stance Action Taken

AI-generated response summary

• Borough Care devised a form for managers to complete weekly to inform the Head of Care of significant incidents. • The new form was introduced to all managers on 26th October and implemented the following Monday. • Incidents reported via the form are discussed weekly at Care & Quality meetings, with follow-up actioned by Area Support.

View full response

Dear Mr Morris Thank you for your correspondence of 14th November regarding the Death of Kathleen Smith: Following the Inquest; have taken on board your comments regarding head office not aware of incidents that happen in the individual care homes within Borough Care Ltd. Borough Care Ltd do expect our Managers to keep us informed of events that happen in the home: However; on this occasion the manager did not inform the Head of regarding the fall that Mrs Smith had or the injury that was incurred: This should have happened as a matter of procedure. therefor devised a form that managers must complete on weekly basis to inform Head of Care of any significant incidents that happen in the home: These incidents are discussed weekly at our Care & Quality meetings and any follow up is actioned by the Area Support for that Home: This form was introduced to all Managers on the 26th October at our monthly Managers meeting and was actioned by the Managers from the following Monday: Our Quality Manager and Area support team also ensure that any incidents are discussed on their audit meetings with the Home Manager: It is unfortunate that the Manager of Lisbume Court at that time did not follow procedure and as discussed in Court the Manager left the service, however if she hadn't left the service her capability to manager was under scrutiny and action would have been taken: have enclosed two copies of the form completed weekly by the ManagerIDeputy Manager: INVESTORS Silver Bcrough Care Limiled is an Induslrlal end Frovident Sociely wilh charitable $alys; IN PEOPLE Registered Ofica: Acorn Business Park; Haaton Lana Stockpont Sk4 JAS Reg stered number 277883 being Care have will

Report sections

Investigation and inquest

On 13th June 2017, Chris Murray, Assistant Coroner for Manchester South, opened an inquest into the death of Kathleen Smith who was aged 80 when she died at her care home on 4th June 2017_ The investigation concluded at the end of the inquest which heard on 20th October 2017. The conclusion of the inquest was that Mrs Smith died as a result of a stroke whilst being in the advanced stages of dementia. Whilst this is a natural cause of death, the inquest concluded her death was contributed to by a hip fracture sustained on 12th April 2017at her care home when she fell to the floor having been pushed by another resident: At the end of the inquest, recorded a Narrative Conclusion to this effect_

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Shared signals

Report details

Reference: 2017-0397
Date of report: 14 November 2017
Coroner: Chris Morris
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: 12 Apr 2018 (estimated from the Judiciary.uk publication date).

Sent to

Borough Care

Part of a series

2 reports

2019-0184 All responses identified

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.