Source · Prevention of Future Deaths

Winston Harris

Ref: 2016-wp25349 Date: 3 Aug 2016 Coroner: Louise Hunt Area: Birmingham and Solihull Responses identified: 2 / 3 View PDF

The care plan for Mr Harris did not address his risk of absconding, and hospital staff did not consider an emergency DOLS despite his dementia and previous attempts to leave; the DOLS application was not processed before his death.

Date 3 Aug 2016

56-day deadline 28 Sep 2016 est.

Responses identified 2 of 3

Care Home Health related deaths Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

9 Kerria Court residential home (1) The care plan for Mr Harris did not deal with his risk of absconding. As a result when he was transferred to City Hospital with his care plan there were no details of his previous absconding behaviour. (2)When Mr Harris was transferred to hospital, without an escort, there was no written documentation provided to confirm that a DOLS had been applied for and that he was an absconding risk. Sandwell and West Birmingham Hospitals NHS Trust (3) At no time did staff consider if Mr Harris should be subject to an emergency DOLS despite him having dementia and having tried to leave the ward on 16/03/2016. He had previously been assessed as requiring and DOLS. Birmingham City Council (4) The application for DOLS order was not processed before Mr Harris's death. I heard evidence that it often takes many months to process a DOLS application. Given these are extremely vulnerable people applications should be processed more quickly.

Responses

2 respondents

Birmingham City Council Local Authority / Fire Service

PDF

Noted

Birmingham City Council acknowledges the DOLS application backlog and states that great efforts have been invested, which is now delivering significant results and reducing the waiting list. They clarify that DOLS approval is setting-specific and has no bearing on a care provider's duty to ensure patient safety and supervision. (AI summary)

Sandwell and West Birmingham NHS Trust NHS / Health Body

PDF

Action Planned

Sandwell and West Birmingham Hospitals NHS Trust plans to implement an aide memoire for staff by end of October, continue auditing DOLS compliance, and deliver ongoing education and awareness programs. They also plan to use KPI reporting and in-house inspections to monitor DOLS application numbers and timeliness, with an electronic patient record due by Christmas 2017 to further improve monitoring. (AI summary)

Report sections

Investigation and inquest

On 06/04/2016 I commenced an investigation into the death of Winston Harris aged 76 who resided at Kerria Court residential home. The investigation concluded at the end of the inquest on 3rd August 2016. The conclusion of the inquest was that the deceased died from dilated cardiomyopathy contributed to by hypothermia and acute kidney injury which occurred after he absconded from City hospital on 17/03/2016. The medical cause of death was 1a. Pulmonary oedema 1b. Dilated cardiomyopathy 1c. Acute kidney injury and hypothermia in a patient suffering from dementia

Circumstances of the death

Mr Harris was a resident at Kerria Court as he suffered from dementia. He was admitted to the residential home on 05/02/2016. He absconded from the home that day due to his dementia. He was assessed as lacking capacity to make decisions for himself and an application for a deprivation of liberty safeguarding order (DOLS) was made to the local authority. On 12/03/2016 he complained of chest pain and was taken to City Hospital. His previous absconding and the fact that a DOLS application was being made was provided to the paramedics orally only. The care plan that accompanied the deceased to hospital did not mention the previous absconding or the DOLS application. The deceased was investigated at City Hospital and moved to several different wards. He was noted to be pleasantly confused. An echocardiogram confirmed severe right and left ventricular systolic impairment indicating dilated cardiomyopathy. He was transferred to ward D7 on 15/03/2016. On 16/03/2016 Mr Harris had attempted to leave the ward. As a result the door security was changed so that only staff could enter or leave the ward with security passes. On 17/03/2016 CCTV confirmed that Mr Harris left the ward behind a member of staff at 10.57 fully clothed, he then exited the hospital at 11.07 and was last seen walking down Aberdeen Road at 11.12. The police were informed. On 18/03/2016 the deceased was found sitting at a bus stop and paramedics were called at 08.21, arriving at 08.34. Mr Harris was taken to Queen Elizabeth Hospital In Birmingham where he was found to have an acute kidney injury and be severely hypothermic. He continued to deteriorate and passed away on 22/03/2016.

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Report details

Reference: 2016-wp25349
Date of report: 3 August 2016
Coroner: Louise Hunt
Coroner area: Birmingham and Solihull

Responses identified

Responses identified 2 of 3

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 28 Sep 2016 (estimated).

Sent to

Birmingham City Council

Kerria Court residential home

Sandwell and West Birmingham Hospitals NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.