Source · Prevention of Future Deaths
John Atkin
Ref: 2017-0064
Date: 6 Mar 2017
Coroner: Anna Crawford
Area: Surrey
Responses identified: 0 / 1
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There is a critical breakdown in communication regarding hazard assessment at service-user homes, with occupational therapists unaware of their role in informing delivery services about potential dangers, and no policy preventing drivers from entering without prior contact.
Date
6 Mar 2017
56-day deadline
1 May 2017 est.
Responses identified
0 of 1
Coroner's concerns
There is a critical breakdown in communication regarding hazard assessment at service-user homes, with occupational therapists unaware of their role in informing delivery services about potential dangers, and no policy preventing drivers from entering without prior contact.
View full coroner's concerns
The court heard evidence that Millbrook expects the healthcare professionals ordering a particular piece of equipment to assess whether the service-user’s home poses any potential hazards to Millbrook’s delivery drivers, and to inform Millbrook of any such hazards when they place an order. During the course of the inquest the court heard from the two occupational therapists who were involved in prescribing and ordering the piece of equipment that Mr Atkin delivered on 23 February 2016. They told the court that they do not always assess service-users at their home addresses and do not routinely ask service-users about the presence of pets in their homes. They were not aware that they were expected to assess potential hazards to Millbrook’s delivery drivers, and said that they only passed on such information if they were aware of it. The court heard evidence that Millbrook is due to roll out a new system which will require healthcare professionals ordering equipment to specify whether or not there is a dog at a service-user’s address. The company has not carried out any consultation with its clients regarding the introduction of the new system, and whether it is realistic to expect healthcare professionals to obtain this information from their patients/clients. The court also heard evidence from an inspector at the Health and Safety Executive. As part of his investigation into Mr Atkin’s death he had carried out enquiries with the Royal Mail and a representative of the white goods industry with respect to industry practice. He told the court that members of the industry did not routinely ask in advance about potential hazards at addresses, but that it was accepted practice at both the Royal Mail and within the white good industry to have a policy in place to prevent employees from crossing the threshold into a person’s home until they had made direct contact with the homeowner. Millbrook currently operates on the basis of an inaccurate assumption that enquiries with regard to whether there are any hazardous dogs at a service-user’s address are carried out by the healthcare professionals who order the equipment from them.
- There is no policy in place at Millbrook which prevents driver/ technicians from entering a service-user’s address before they have made direct contact with the home owner. Consideration should be given to whether any steps can be taken to address the above concerns.
!3
- There is no policy in place at Millbrook which prevents driver/ technicians from entering a service-user’s address before they have made direct contact with the home owner. Consideration should be given to whether any steps can be taken to address the above concerns.
!3
Report sections
Investigation and inquest
An investigation was commenced on 4 March 2016 and the inquest into the death of John Atkin was opened on 13 May 2016. It was resumed on 8 February 2017 with a jury. The jury returned their conclusion on the 13th February 2017, having been in retirement for 4 hours and 53 minutes. They found the medical cause of death to have been: 1a. Staphylococcal Septicaemia 1b. Dog bite wound of the hand II. Diabetes Mellitus
They concluded with a short form conclusion of ‘Accident’. !1
They concluded with a short form conclusion of ‘Accident’. !1
Circumstances of the death
John Atkin was a Driver/Technician for a company called Millbrook Healthcare Limited (Millbrook), a company that delivers and installs healthcare equipment at service-users’ homes. Healthcare professionals use a web-based system to order equipment from Millbrook on behalf of their patients/clients. The court heard that, due to the nature of its business, a significant proportion of the people to whom Millbrook delivers have difficulties with their mobility. On 23 February 2016 Mr Atkin was tasked to deliver and to install an item of equipment at the home of an individual who had recently undergone an amputation of her leg. On the job sheet Mr Atkin received he was instructed to go directly into the service-user’s home because she could not come to the door. On arrival he duly entered the premises where he was bitten by the service-user’s spaniel dog. The court heard that Mr Atkin then returned to work and the wound was washed and dressed by the first aider. The first aider advised Mr Atkin to go to hospital but he declined. He continued to go to work over the next few days but began to feel increasingly unwell. On 26 February 2016 he left work early complaining of feeling ill. On 27 February 2016 he was found deceased at his home address. !2
Copies sent to
2. Surrey County Council3. St. George’s University Hospitals NHS Foundation Trust5. Health and Safety Executive
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Report details
- Reference
- 2017-0064
- Date of report
- 6 March 2017
- Coroner
- Anna Crawford
- Coroner area
- Surrey
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: 1 May 2017 (estimated).
Sent to
- Millbrook Healthcare Limited