Source · Prevention of Future Deaths

Roger Tombs

Ref: 2017-0027 Date: 13 Feb 2017 Coroner: Emma Brown Area: Birmingham and Solihull Responses identified: 2 / 3 View PDF

Fall sensor mats were improperly placed on crash mats, potentially reducing their effectiveness and increasing the risk of undetected falls, injury, and death for vulnerable residents.

Date 13 Feb 2017

56-day deadline 10 Apr 2017 est.

Responses identified 2 of 3

Care Home Health related deaths

Coroner's concerns

AI summary

Fall sensor mats were improperly placed on crash mats, potentially reducing their effectiveness and increasing the risk of undetected falls, injury, and death for vulnerable residents.

View full coroner's concerns

The MATTERS OF CONCERM are as follows. The evidence was that fall sensor mats had been placed either side of Mr. Tombs' bed on top of crash mats. At the time of his fall on the 3rd May 2016 the sensor mats did not sound an alert The instructions for use of the sensor mats state should be placed on a hard floor. The investigating police officer from the public protection unit gave evidence that she was concerned that the crash mats below the sensor mats would reduce the effectiveness of the sensor mats and this could possibly be the reason the mat didn't sound (there were other possible explanations): The evidence was that Sunrise of Knowle is still placing sensor mats on top of crash mats_ No expert opinion has been sought on this practice but the evidence of the investigating police officer was that the managing director of the local distributors of the mats told her this was an May they unsafe practice in his view. It is my opinion that there is a risk that the effectiveness of the sensor mats is being reduced by placing them on crash mats and if this is the case may not sound when vulnerable residents are mobilising exposing them to a risk of falls, injury and potentially death

Responses

2 respondents

Sunrise Senior Living Other

28 Feb 2017 PDF

Noted

Sunrise Senior Living acknowledges the report but states it is leaving the Home's management and registration with CQC on 1 March 2017. It invites dialogue and can describe immediate actions taken after the inquest but not future measures. (AI summary)

View full response

Dear Ms Brown

Roger Harold Tombs (Deceased)

I refer to the Regulation 28 Report to Prevent Future Deaths arising out of the Inquest into Roger Tombs dated 13 February 2017 (“PFD Report”) addressed to Sunrise Senior Living (“SSL”).

As you are aware SSL is one of the providers registered with the Care Quality Commission in respect of Sunrise of Knowle (“Home”). SSL became registered with the CQC in October 2016 and manages the Home on behalf of Sunrise Operations of Knowle Limited (“SOK”), the other registered provider. SSL was also managing the Home at the time of Roger Tombs’ death on behalf of SOK.

It is expected that SSL will be leaving the Home and will be deregistered by CQC on 1 March 2017, with another provider coming in to manage the Home and who will be registered with CQC. SOK remains registered with the CQC.

With the imminent departure of my Client from the Home, I would be grateful if you were able to provide guidance on how you would like my Client to respond to the PFD Report. My Client has written to CQC and Solihull MBC Falls Team inviting them to engage in a dialogue

on the matters raised in the PFD Report to help SSL inform its Response (copies of the letters are attached).

My Client will be able to inform you of the steps it took immediately following the Inquest to address the matters of concern raised by you in respect of the placing of sensor mats on top of crash mats at the Home, but it will not be in a position to describe any measures that may be implemented at the Home post 1 March 2017.

My Client would welcome your views on the above and I look forward to hearing from you.

Roger Tombs NHS / Health Body

20 Apr 2017 PDF

Action Taken

The Falls Team reviewed its practices after the PFD report and found them consistent and accurate. A guidance document outlining good practice in sensor mat use was developed and sent to the local council for circulation to care homes in the borough. (AI summary)

View full response

Dear Ms Brown

Roger Harold Tombs (Deceased)

I refer to the Regulation 28 Report to Prevent Future Deaths arising out of the Inquest into Roger Tombs dated 13 February 2017 (“PFD Report”) addressed to Solihull Falls Team (SFD). Firstly, I wish to thank you for the extended time period to respond to this report. The Falls Team was not directly involved in, or present, at the inquest and therefore did not have the opportunity to represent themselves or explain any actions taken in respect of falls prevention training that was provided to the Sunrise Care Home. All conversations related to the case were with the police officer, Sarah Vaughan, and were conducted via telephone following the conclusion of the inquest. Nursing staff working within the Falls Team were contacted by Ms Vaughan to discuss the advice given by the team to Sunrise Care Home in relation to the correct use of sensor mats. The Nurse Lead informed Ms Vaughan that neither she nor any other member of the team had been directly involved with the Mr Tombs’ care, and that the advice that had been provided to Sunrise was standard guidance on the appropriate use of crash mats and sensors. It was confirmed to Ms Vaughan that the standard guidance and training would not have advocated the use of the sensor mats being place on top of crash mats. It can be only be assumed that Sunrise Care Home have misinterpreted the advice provided by the Fall Team which is supplemented by the recommendation that each resident would also need a holistic risk assessment to ensure measures could be put in place to meet each individual’s need. As we are concerned to hear that Sunrise Care Home are still using the sensor mats incorrectly, and as a direct result of the issuing of the PFD Report, I have reviewed practice within the team in

relation to the issue of advice and training of this nature and find that it is both consistent and accurate. Furthermore, to support the dissemination of this across the care home sector, a guidance document has been developed outlining good practice in the use of sensor mats and is enclosed for your reference. This was sent on 4 April 2017 to Theresa Scragg - Acting Strategic Commissioner for Older People, Solihull Metropolitan Borough Council (SMBC), for circulation throughout all care homes in the borough. It is my understanding that Ms Scragg intends to add to this guidance and supplement this with further information related to assistive technology available through SMBC but I have not yet seen this additional material. Please do not hesitate to contact me if you require further information

Report sections

Investigation and inquest

On 25/05/2016 commenced an investigation into the death of Roger Harold Tombs. The investigation concluded at the end ofan inquest on 9th February 2017. The conclusion of the inquest was: "Mr Tombs died as a result of an accidental fall: His needs had not been adequately re-assessed following a deterioration in his condition, which contributed to his death_ In addition the jury made findings on the central issues ofthe case which were;
1. Was there any error or omission in the level of care provided to Mr Tombs that caused or contributed to his death?

Circumstances of the death

On the 4th 2016 at 03.30,Roger Harold Tombs died at Queen Elizabeth Hospital, after admission following a fall at Sunrise Care Home in Knowle on the 3rd May 2016. Roger was subject to a Deprivation of Liberty Safeguarding Order, due to his learning disabilities. He was at high risk of falls and had had an increase in falls leading up to his death: Following post mortem, the medical cause of death was determined to be: 1a BRONCHOPNEUMONIA lb SEVERE TRAUMATIC BRAIN INJURY

Action should be taken

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

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2017-0027
Date of report: 13 February 2017
Coroner: Emma Brown
Coroner area: Birmingham and Solihull

Responses identified

Responses identified 2 of 3

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 10 Apr 2017 (estimated).

Sent to

Care Quality Commission

Solihull Falls Team

Sunrise Senior Living

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.