Source · Prevention of Future Deaths

Ivy Mitchell

Ref: 2017-0453 Date: 18 Jul 2017 Coroner: Alison Mutch Area: Manchester (South) 1 response identified · 2 indexed addressees View PDF

AI-generated concerns summaryThe coroner noted inaccurate falls risk documentation, a lack of staff understanding of risk assessments and post-fall procedures, and non-compliance with escalation processes following a fall. There was also a lack of understanding regarding triggers for community nutrition team referrals.

Date 18 Jul 2017

56-day deadline 12 Sep 2017 est. estimated from the report date

Responses identified 1 of 2

Care Home Health related deaths

Coroner's concerns

AI summary

The coroner noted inaccurate falls risk documentation, a lack of staff understanding of risk assessments and post-fall procedures, and non-compliance with escalation processes following a fall. There was also a lack of understanding regarding triggers for community nutrition team referrals.

View full coroner's concerns

1. The documentation relating to the falls risk was inaccurate. It did not refer to previous falls and did not reflect her mobility;
2. There was a lack of understanding amongst the care home staff of risk assessments; reviews and the required process following a fall: This included documenting observations after a fall:
3. Processes relating to escalation following a fall were not complied with; and
4. There was a lack of understanding of the trigger for a referral to the community nutrition team

Responses

1 respondent

Fairfield View Care Centre

Other

Indexed date: 1 Sep 2017 PDF

AI-classified response stance Action Taken

AI-generated response summary

• The care centre audited documentation related to falls and mobility for all service users. • Senior staff attended a meeting on documentation and falls procedures, and this information was cascaded to staff. • The centre will implement daily and weekly audits of care plans and daily records, and staff will undertake a care planning course.

View full response

Dear Miss Mutch Re: Mrs Ivy Mitchell [enclose my reply, in response to regulation 28 in the case of Mrs Mitchell; have now audited all the documentation in relation to falls and mobility of all the service users. In relation to Mrs Mitchell; accept that the documentation and risk assessmenls did not accurately rellect her falls or mobility, which has caused me concem Senior staff attended the meeting held in relation to documentation and the falls procedure: Delails of which; enclose. This information has been cascaded down lo staff, and the importance of completing all the relevant documentation was discussed at length. have emphasised (he failings in relation to Mrs Mitchell, and that we must ensure it does not happen to any of the service users. am now puditing all care plans and daily records on daily and weekly basis, to ensure accuracy regarding risk assessments, and that documentation in the event of a fell is completed accurately and in & timely manner: Unit Managers, Deputies and Senior Care Staff are undertaking a course on care planning, this will commence in Scptember of this with Tameside College This will include how to complete an accurate risk assessment as well as identifying the needs ol the service user: This course will provide them with more knowledge about the importance of documentation and ofthe need lo involve the service user, where (herc is copacity, or (heir relatives in all care planning activities. have made staff aware of the referral process that needs t0 be completed where there is 0 cause for concem over the nutritional slatus of a service user: This is an area that will also be auditing on & regular basis and giving advice about relerrals where feel it is necessary to do so. have enclosed the nutritional referral form that is used by the Community Dicticians for all referrals in the community: Fairlield View Cart Cenlrc; BB Alanchesler Raad. Audunshaw Manclister MJ4 SGB CHAT Telephnne: 016/. 770} 6714 Far: 0161.770 8419 Oirttes AbtrUah # Alrerah #ktrJit IN"EnOx IkItuLc Ivy great again year again

my response addresses your concerns in relation to the regulation 28 notice: Ifyou require any further information on this matter; please do not hesitate to contact me.

Report sections

Investigation and inquest

On 27Tk January 2017 commenced an investigation into the death of Ivy Mitchell: The investigation concluded on the 11th July 2017 and the conclusion was one of Narrative: Died as a result of natural causes with a contribution being made by injuries sustained in an accidental fall. The medical cause of death was 1a Left sided bronchopneumonia; Il Left subcapital fracture Circumstances of the Death Ivy Mitchell was a resident at a care home: She had a history of falls. On 29th December 2016 she had a fall in room. She appeared to mobilise afterwards. On the evening of 29th December she said she felt unwell. On 3Oth December following a discussion with her GP , a taxi was called and she went to Tameside General Hospital. A subcapital fracture and pneumonia was diagnosed. She was initially too unwell for surgery: She was operated on, on 7th January 2017. She dislocated her hip on 19th January 2017 but was not suitable for further surgery. She began to show further signs of infection on 2Sth January 2017. She deteriorated and died on 26th January 2017. CORONER'S CONCERNS During the course of the inquest, the evidence revealed matters giving rise to concern: In my opinion, there is a risk that future deaths will occur unless action her is taken. In the circumstances, it is my statutory duty to report to you: The MATTERS OF CONCERN are as follows.
1. The documentation relating to the falls risk was inaccurate. It did not refer to previous falls and did not reflect her mobility;
2. There was a lack of understanding amongst the care home staff of risk assessments; reviews and the required process following a fall: This included documenting observations after a fall:
3. Processes relating to escalation following a fall were not complied with; and
4. There was a lack of understanding of the trigger for a referral to the community nutrition team ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and believe you have the power to take such action: YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report; namely by 12th September 2017. |, 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, vou must explain why no action is proposed; COPIES and PUBLICATION have sent a cOPy of my report to the Chief Coroner, CQC and to the following Interested Persons namely daughter of the deceased, who may find it useful or of interest_ am also under a 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 ofyour response by the Chief Coroner. Alison Mutch O.B.E HM Senior Coroner 18th July 2017 duty

Action should be taken

In my opinion, action should be taken to prevent future deaths and believe you have the power to take such action:

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Shared signals

Report details

Reference: 2017-0453
Date of report: 18 July 2017
Coroner: Alison Mutch
Coroner area: Manchester (South)

Responses identified

Responses identified 1 of 2

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 12 Sep 2017 (estimated from the report date).

Sent to

Fairfield View Care Centre

Tameside Borough Council

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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