Ronald Farrington

Coroner's concerns

AI summary

The care centre failed to implement specialist nursing advice, kept inaccurate records, and didn't seek medical attention for infection, exacerbated by inadequate tissue viability nurse staffing and poor CQC oversight.

View full coroner's concerns

1. Nuffield Care Centre:
a.) Failed to incorporate all the advice given by the tissue viability nurses in Mr Farrington’s care plans.
b.) Failed to keep accurate records.
c.) Informed the CQC that the tissue viability nurses were still involved with Mr Farrington when they weren’t.
d.) Failed to follow the advice of the tissue viability nurses as to turning and how to dress Mr Farrington’s sores
e.) Failed to refer Mr Farrington to his General Practitioner when he developed an infection in the sacral pressure sore on the 1st June 2016.
2. Only one tissue viability nurse was employed by First Community Care from March 2016 onwards. They were on annual leave for 6 weeks between the 18th March and the 15th June 2016. This was not an adequate level service.
3. The CQC did not obtain independent evidence about Mr Farrington’s care having received 2 notifications that he had developed pressure sores.
4. Mr Farrington’s family who visited him on a very regular basis and could have provided information about his care were not made aware that he had developed pressure sores, nor that the CQC were conducting any enquiries.
5. A large scale review has been convened as a result of the safeguarding alert raised by East Surrey Hospital. It is now being conducted by Surrey Adult Safeguarding. As at the date of the resumed Inquest no adequate s42 report has been written. The family have not been invited to take part in the review. No adequate enquiry has been made.

Responses

2 respondents

Response

22 Dec 2017 PDF

Action Taken

Surrey County Council has improved systems to identify long running adult safeguarding enquiries and take actions to bring them to a satisfactory conclusion, and has reduced the percentage of enquiries in progress for over 12 months. (AI summary)

View full response

Dear HM Coroner

 There was inconsistent management oversight. No one person consistently managed the process throughout and as a consequence actions were not followed through in a timely, meaningful way  Our adult safeguarding policies and procedures do not set out well enough what can be expected when we require others to make enquiries for the purposes of s42 of the Care Act 2014  Our systems were not effective in identifying and rectifying where adult safeguarding enquiries were taking too long

Following the Inquest, Surrey County Council Adult Social Care services have worked with Nuffield Care and the family to complete a meaningful adult safeguarding enquiry that meets the requirements of s42 of the Care Act and the associated statutory guidance. Mr Farrington’s family will be invited to an outcomes meeting with Nuffield Care and Adult Social Care in February where the family will be able to express their views and concerns.

We have improved our systems to identify long running adult safeguarding enquiries and take actions to bring them to a satisfactory conclusion. In December 2016 15% of our adult safeguarding enquiries had been in progress for over 12 months. By December 2017 we had reduced this to 4%, despite the number of adult safeguarding enquiries we are undertaking having more than doubled over that period. We are confident we can sustain this improved performance.

We have also put in place a revised quality assurance auditing programme of our adult safeguarding work so that we can more readily identify when our adult safeguarding work is falling short of expectations and take action to address this.

We are in the process of revising our adult safeguarding policies and procedures, and working with our colleagues on Surrey Safeguarding Adults Board to improve the Board’s policies and procedures, so that

 they set clearer expectations of how adult safeguarding enquiries should be planned so that they involved the adult with care and support needs and their family; and  they support better practice by Adult Social Care staff in setting expectations for contributions required from other organisations to s42 Care Act enquiries  Clearly identify for each adult safeguarding enquiry who has the responsibility for ensuring that enquiry is timely and effective and to monitor the actions required

We expect these policies and procedures to be in place by April 2018, when they will be followed by a learning and development programme to support our staff to understand and be able to meet the expectations on them. We will also review our systems to ensure they are able to support the practice we expect and produce better management information to help oversee the work. We expect this work to be completed by October 2018.

Ronald Farrington

PDF

Action Taken

The care home has implemented structures and processes to avoid similar situations, including computerized care plans for wound and tissue care, regular reviews, and updates based on professional visits, audited by staff and SMT. (AI summary)

View full response

Response_to coroners concerns_Nuffield Mr Farrington passed away on the 21" June 2016 which is some 18 months ago now: We have initially provided evidence from external agencies of the changes that have happened in this time and then specifically answered the questions raised following the inquest. We believe that the evidence provided shows that following the improvement plan there are now structures and processes in place to avoid such situations and that these are now embedded in the culture of the home_ In the period following June 2016 there has been a considerable amount of work completed with the Surrey Downs Clinical Commissioning group and their report from 2017 states the following; On the day of the visit we sampled 3 care files, one of which was the deceased and part of the LSE, The focus was on Wound and Tissue viability within the care plan. We looked at; Wound Care plans Wound continuation rnonitoring charts Tissue Viability Care plans Tissue continuation monitoring charts We were told and shown by the manager that the home operates a computerised system to record care plans_ The wound and tissue care plan are generated from the computer programme. Both the wound and tissue continuation monitoring charts were written by hand, The home manager explained the home would complete a wound and tissue viability care plan if the skin was broken and if a dressing had to be used Wound and tissue continuation monitoring charts would be in place to monitor the area, and to demonstrate that correct treatment had been given in line with professional recommendation that woulcl appear within the care plan_ On one file there were 4 wound care plans in place. They had been regularly reviewed, hence there were several versions for the same wound. The care plan had been updated either when the wound had changed its grade or if a professional such as the tissue viability nurse had visited: A follow up visit was made on 17lh October to look at the improvements made around Care Planning in relationship to Wound Care. The wound care plans had greatly improved the information was well laid out and there was clear instructions to staff how any wound needed to be treatment and what materials to use.

We were shown a folder thaf was well presented of all the wounds including pressure sores and skin tears on the top unit: The home had put in place a formal wound assessment plan that gave staff an aid memoir to all the areas they should be consicering When recording progress of a wound We were able to see an audit that the manager had completed looking at all the wound care plans. We were also inspected by CQC on the 12th July 2017 and their inspection report states: "there were up to date risk assessments in place for those who may he at risk of falling Or cleveloping pressure sores These were reviewed regularly. One person who was at risk Of developing a pressurc sore had been placed had been placed 0n an air mattress to recice (he likelihood of this which was regularly checked. Inicidents and acciclents were nOW reviewed and action taken to acdress and regular patterns or trends that may he identified a) Since this time we have in place a new auditing system with close support from the local quality development team from East Surrey, this has been developed over the past year and has been met with positive feedback from the local team_ The manager carries out weekly wound audits which are then audited monthly by the General manager: There is also a monthly managers audit which includes care plans and this ensures that the care plans are current relevant and evidence based, any issues identified then lead to an action plan that is audited during the next month b) As part of the monthly audit completed by the manager and sent to the senior management team who then audit this random samples during very regular visits the daily recordings such as care notes turning charts are checked for accuracy and relevance The Information given to cqc was that the tissue viability nurse had been Involved and the measures described above are in place to ensure that the advice Is followed or that clear rationale is given when there is a departure from the advice, (in this instance we would be asking the relevant professional to endorse the changes or departures made) The auditing process that has been actioned since these events are part of the process to ensure that advice given is followed or clear rationale given when other methods are employed; being put using and given

e) Part of the audit process is reviewing care plans and would ensure that the action given in the care plan is followed. There was no tissue viability nurse for an extended period of time which was not acceptable there had not been any acceptable replacement provision provided. In future the service will give consideration to raising this as a safeguarding concern 3 , We not be able to dictate what action cqc will take but the governance improvements we have put in place are designed to ensure that the care provided is based upon evidence and has been audited by both the staff within the home and the SMT. When CQC are carrying out an inspection they always ensure that there is a sign displayed for families and visitors to make them aware of the inspection. Staff are aware that when discussions are held with family members this should be documented in the appropriate notes to provide evidence that thls has occurred and further it should also be documented if the service user has indicated that do not wish for any information to be shared_ 5, We were asked for and provided a chronology of events, at no point were we asked for anything further by Surrey Adult Safeguarding: We not initially carry out an internal investigation as we would usually be advised not to while any further Investigations such as police investigations or open safeguarding reviews are completed. It Is standard practice that this would be the case, however the increased governance processes we have put In place has been designed implemented and reviewed successfully to avoid similar situations in the future. It is to be hoped that the change in processes within the local authority will mean that in future where appropriate families will have an increased involvement but this is not something we would be able to action_ MK 19,01.18 would they did

Saffronland Homes 'Dyty [8741 rpr( Head Office: Maple House; 121B Winchester Road, Chandlers Ford, Hampshire SO53 2R INVESTPES Tel: (023) 8027 0310 Fax; (023) 8027 0320 www saffronlandhones= coi

Report sections

Investigation and inquest

An inquest into the death of Mr Ronald Arthur Farrington was opened on 5th May 2017 and resumed on 2nd November 2017.It was concluded on 17th November 2017. I concluded that Mr Farrington died on the 21st June 2016 at East Surrey Hospital, 1 Canada Avenue, Redhill, Surrey and that the medical cause of his death was; 1a Sepsis 1b Pressure ulcer of the sacrum and pneumonia II Neuro-degenerative disease, dementia and cerebrovascular disease.

I found as follows: Ronald Arthur Farrington became resident at the Nuffield Care Centre in August 2014. He was at high risk of developing pressure sores and developed a sacral pressure sore by January 2015.Tissue viability nurses gave advice to the Nuffield Care Centre from January 2015 until October 2015. Some of their advice was not followed, in particular he was not turned on a 2 hourly basis as required from September 2015. He developed further pressure sores. No further advice was sought from the tissue viability nurses until a referral was made on the 1st June 2016. By then he had a Grade 4 sacral pressure sore which had become infected. No medical treatment was sought in respect of the infection from his general practitioner. The tissue viability nurse was unavailable until the 29th June and was not alerted to any urgency. He was admitted to East Surrey Hospital on the 15th June 2016 suffering from sepsis caused by the infection in the sacral pressure sore. He developed pneumonia in hospital, this contributed to the sepsis. Despite appropriate treatment he died from sepsis in hospital on the 21st June 2016. The conclusion was: Natural causes contributed to be neglect.

Circumstances of the death

Mr Farrington was admitted to the Nuffield Care Centre, Haigh Crescent, Redhill, Surrey, RH1 6RA, a registered nursing home, on the 6th August 2014.He was suffering from Dementia and Parkinson’s Disease. He became bedbound. In January 2015 a referral was made to First Community Care who provide the tissue viability nurse service in Surrey. The advice given by the tissue viability nurses was incorporated into his care plan in May 2015 which included repositioning every 4 hours. He was discharged from the tissue viability nurse service in July 2015. In September 2015 he was re-referred to the service with a grade 4 sacral sore. Concerns were raised by the tissue viability nurse that her earlier advice had not been followed. Further advice was given including that Mr Farrington be turned every 2 hours. This advice was not recorded in the care plan. In the absence of any further requests for advice from Nuffield Care Centre Mr Farrington was then discharged from that service. Nuffield Care Centre made 2 referrals in 2016 to the Care Quality Commission (the CQC) in respect of Mr Farrington’s sacral pressure sores. On each occasion the CQC accepted the written assurance of the registered manager that Nuffield Care Home was following the advice of the tissue viability nurses. No independent investigation was conducted, neither First Community Care nor the family were asked to provide any information. The information provided by the registered manager was incorrect. In November 2015 the CQC undertook an inspection of Nuffield Care Centre and the inspectors were told there was ongoing tissue viability nurse involvement with Mr Farrington which there was not. Mr Farrington was not being turned on a 2 hourly or even 4 hourly basis. On 16th March 2016 First Community Care sent a letter advising Nuffield Community Care that they now only retained one tissue viability nurse and in her absence on annual leave for 4 weeks they should contact the patient’s general practitioner with any issues requiring tissue viability advice. , Mr Farrington’s doctor, said this would not be within his expertise. On the 1st June 2016 staff at Nuffield Care Centre recorded that Mr Farrington’s wound looked infected and was not improving. A further referral was made to First Community Care on the 1st June 2016. This went unanswered until the 15th June 2016 because the tissue viability nurse was again on annual leave. Mr Farrington’s care plan required any sign of infection to be referred to his General Practitioner. This was not reported to

. Mr Farrington developed sepsis from the infected pressure sore. He was admitted to East Surrey Hospital, 1 Canada Avenue, Haigh Crescent, Redhill, Surrey, RH1 6RA on the 15th June 2016. Despite appropriate treatment in hospital Mr Farrington died on the 21st June 2016.

Similar PFD reports

Shared signals

Coroner's concerns

Responses

Report sections

Similar PFD reports

Related inquiry recommendations

Report details

Responses identified

Sent to

Source links