Raymond Shepherd

Coroner's concerns

AI summary

Poor record-keeping and unupdated customer files led to missed care visits and unaddressed patient deterioration. Repeated falls and health concerns went without appropriate referrals or a mental capacity assessment.

View full coroner's concerns

In the circumstances it is my statutory to report to you: The standard and detail of the record keeping in the Home Care Support_ day call leg duty .

Service User comment book was Of very poor standard: The Home Care Support Customer file does not seem to have been updated and reviewed:
3. On some occasions both visits were not undertaken_ From 18 January 2016 there were at least three occasions when the deceased had either reported a fall or been found having after fallen, but no action was taken to the GP or ambulance service. 5_ The deceased was a service user with chronic health problems which aftected his mobility and was at high risk of suffering a fall as well as self-neglect: He reported not wishing to eat anything over a period of days which again should have triggered some concern: Over a period of some there seems to have been a deterioration in his condition which could have been identified and steps taken to stop it by appropriate referrals to primary health care services. In the event that led him to having a further significant fall in which he fractured a femur as well as sustaining other injuries_ This in turn led to a hospital admission but he was not fit enough to undergo surgery and died: There was no mental capacity assessment undertaken or a review of this arranged:

Responses

1 respondent

Human Support Group

14 Feb 2017 PDF

Action Taken

The Human Support Group has implemented several changes including revising the care planning process, incorporating falls prevention information into training, developing a falls poster, reviewing care planning matrix, and adding fields to the electronic rota system for recording falls data. (AI summary)

View full response

Dear Sir

Information for consideration

This response is in relation to the Regulation 28 Report issued on 30.12.2016 by email to members of the Human Support Group into the death of Mr. Raymond Shepherd, as part of my formal response, I wish to put forward some information to be considered. The comments book/daily record that is referred to in the report, was to our knowledge, still at the home of Mr. Shepherd at the time of his death in hospital. The information about the falls was only fully made available during the court hearing when it was given to (Area Manager). As a Company, we were not invited to participate in any of the strategy meetings held by Trafford Council and we were not given the opportunity to be able to fully prepare for or to respond to the court’s questions about information held in the comments book until the information was presented during the inquest.

1.Missed visits

Following on from the inquest, we have had time to look at digital telephone call records as well as our Rota system regarding the dates of the missed visits referred to in the report. The report refers to missed visits on 16th January, 17th January, 19th January and 22nd January 2016. Please see the following information:-

16th January (Saturday) – The most recent commissioning paperwork from Trafford Council dated
10.08.2015 does not schedule a tea visit it on Saturday evenings.

17th January (Sunday) – Sunday evening visits have not been provided since September 2015. A note on the Rota system states that the care plan (on the Rota system) has been amended to cancel the evening visits on Saturday and Sunday nights.

19th January (Tuesday) – Tuesday evening visits have not been provided since October 2015. I understand Mr. Shepherd had a long standing arrangement with a neighbour and they ate together on a Tuesday evening.

22nd January (Friday) – This evening visit was cancelled by Mr. Shepherd. An inbound phone call from Mr. Shepherd’s mobile phone was received at 12.15 cancelling the visit that night, as evidenced from our digital call logs.

2) Ongoing risk of falls

Whilst this doesn’t negate the facts that Mr. Shepherd had several falls between 18th and 23rd January 2016, that they were not reported fully to the Sale office or that a GP was not called for Mr. Shepherd, the paperwork that we have from Trafford Council in 2013 dated over a year before Mr. Shepherd was referred to the Human Support Group in 2014 for the Reablement service and before his long term domiciliary care package was commissioned. This paperwork states Mr. Shepherd was at risk of falls and had declined to have assistive technology or a pendant alarm, preferring to use his mobile telephone to summon help if needed. I can only assume that the date of 2013 on the paperwork was from a previously commissioned care package for Mr. Shepherd from another organisation.

Mr. Shepherd’s long term alcohol abuse was known and well documented and there was nothing to suggest in any of the Trafford Council paperwork that Mr. Shepherd had did not have capacity and he continued to manage his own finances, shopping and medication. Mr. Shepherd was able to communicate easily, and in the three months prior to his hospital admission on 23rd January 2016, 84 phone calls were made by Mr. Shepherd to the Human Support Group. Despite frequent hospital admissions (several due to falls), hospital stays including a notable 12 week stay in late 2015, and discharges as well as district nurses involved in his support, there has been a collective failure from many partner agencies to look at how alcohol affected Mr. Shepherd’s capacity to make day to day decisions.

3) Lack of appetite

Point 5 in the report refers to Mr. Shepherd’s appetite being diminished over a period of days and that this should have triggered concerns. I can’t negate this or explain why this did not trigger concerns from the Care Assistants scheduled to provide care, but it is known that Mr. Shepherd has historically had a poor appetite and had been prescribed fortisips to supplement his daily food intake. It is documented in the section of the comment book sent back as part of the Report that fortisips were given by the Care Assistants.

4) Actions taken/Action to be taken

4.1 Immediately after the inquest was held, I met with (Area Manager) to discuss what had happened at the inquest and to look at plans that could be made going forward and lessons learnt. As information was available to us from the inquest that was not available to us before it took place, we were able to look at digital phone call logs as well as our rota system to look at the alleged missed visits in particular. The Company Board were made aware of the content of your Coroner’s report at the Board Meeting that took place in January 2017.

4.2 A new care plan was already in development and a section was added about risks of falls and falls management. This was introduced to the wider Organisation on 1st December 2016.

4.3 The new care plan was amended during the development phase to look at capacity and substance/alcohol abuse as well as more emphasis on food and nutrition.

4.4 Development of a new falls policy and procedure has been underway in January 2017 and this will be rolled out nationally when completed. Paperwork developed as a result of this review is being tested w/c 13.03.2017 in our Bristol office. All Managers and Quality Monitoring Officers have been made aware there is a new policy that is being drafted and will be soon implemented.

4.5 Although covered already in induction, the updated draft policy has been sent to the Training Manager for incorporation into the induction training for all new staff to start 20.02.2017

4.6 Falls prevention/identification information has been further incorporated into the Care Planning and Risk Assessment training already booked for Quality Monitoring Officers, starting with training in Bristol w/c 13.02.2017.

4.7 A falls poster has been developed and will be distributed to all offices alongside the new policy and procedure when it is completed. It is estimated that this will be w/c 20.02.2017.

4.8 Work around the Mental Capacity Act has been completed with the team in Sale, via meetings, posters and leaflets. The national roll out is being coordinated by Marketing and Communications Manager, .

4.9 has met with the remaining Care Staff involved in Mr. Shepherd’s care between 18-22nd January 2016 to discuss the outcome of the inquest and reflective practice.

4.10 The Sale office care planning matrix has been reviewed by and brought up to date highlighting any care plan reviews that need to be completed. This is reviewed weekly by the Registered Manager. The next internal audit is due at the end of February/Beginning of March and the care planning matrix will be one of the focus areas for the team when auditing the branch.

4.11 Due to different options that falls could be recorded under on the electronic Rota system (Cold Harbour and CM2000) – additional fields have been added to ensure that data can be collected and/or viewed more easily for people who might have had a fall.

As an organisation, we sincerely regret the death of Mr. Shepherd, and will ensure that the appropriate lessons are learned within our service. We will also redouble our efforts to ensure that communication and partnership working between ourselves and statutory health and care services is improved to reduce the likelihood of future incidents.

Report sections

Investigation and inquest

The inquest into the death of Raymond David SHEPHERD was opened on 11 February 2016 and concluded on 30 November 2016_ recorded the medical cause of death to be Ia. Hospital acquired pneumonia, Periprosthetic left hip fracture , alcoholic liver disease, liver cirrhosis, left ventricular failure, COPD, and emphysema. recorded an Accidental Death conclusion:

Circumstances of the death

The deceased was born on 25 July 1953 and lived at Flat 6, 405 City Road, Old Trafford, Manchester. He suffered from chronic iIl health and was only 62 years of age. He suffered from alcoholic liver disease, liver cirrhosis, left ventricular failure, COPD , and emphysema His mobility was extremely limited. He was prescribed medication for his various conditions but continued t0 drink alcohol. He was initially provided with care from February 2014 and then with re-ablement support by Home Care Support after a hospital admission: He then was provided with domestic support from December 2014 and this was funded by Trafford Council:
3. This comprised domestic support which included personal care and cleaning as well as help to produce meals: He managed all of his own medication. He became well known to the Home Care Support carers and would drink alcohol every night and would on occasion refuse_help_ He would also cancel care visits being and because of his poor mobility was unable to get to the toilet and would urinate in a bucket. By the time of the events in question in early January 2016 he was meant to be having two visits a day: His condition had been deteriorating generally over time His Home Care Support customer file identified a number of risks and there was general recognition that he was at risk of falls_ The visiting Home Care Support carers are meant to complete a Service User Comments Book: 6_ A number of issues arise from them. For example, he was meant to have two visits on 16 January 2016 but only one is recorded, similarly on 17 January 2016. On 18 January 2016 in the afternoon visit it was recorded that he had a stomach ache and didn't want anything t0 eat and that he reported that he'd had two falls that day and had banged his head. However; there was no call made to a GP or the ambulance service On 19 January only one visit in the morning is recorded: The following on 20 January 2016 in the afternoon he was found lying on the floor and needed help to get on his feet He claimed that he hadn't hurt himself but didn't want anything to eat Again there was no call to a GP or ambulance service. It is reported that phone call was made to the office about this and should this have happened the court was told that a record should have been kept but it is unclear whether or not any record was recorded and kept in this instance_ On 21 January 2016 in the afternoon it is recorded that he had had another fall overnight and that he wasn't feeling well but still no was made to the GP or ambulance service_ There was a further visit on the morning of 22 January 2016 and he was noted to have a number of bruises and it is recorded that he declined to be checked over by a doctor The entries a sequential and can be read by the staff to see the history: There was no visit recorded in the afternoon of 22 January 2016_
10. On the morning of 23 January 2016 he was admitted to Trafford Hospital having reportedly had a fall that morning having lost his balance whilst walking with a zimmer-frame. He was unable to move his left upwards. He was assessed and diagnosed has having suffered a fracture to his femur as well as an injury to his left shoulder. He was reviewed with a plan to take him to surgery but unfortunately his condition deteriorated and he developed a chest infection. Unfortunately, his condition did not improve despite treatment but deteriorated and he died on 30 January 2016_
11. It is not clear whether or not he had any form of mental capacity assessment undertaken but he clearly was an individual of high risk of self-neglect and suffering accidental trauma:
12. The deceased death was preventable.

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action. YoUR RESPONSE You are under a to respond to this report within 56 days of the date of this report;, namely by Friday 17 February 2017 . I, 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 you must explain why no action is proposed.

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