Source · Prevention of Future Deaths

Marjorie Nesbitt

Ref: 2016-0263 Date: 25 Jul 2016 Coroner: Christopher Dorries Area: South Yorkshire (West) Responses identified: 1 / 1 View PDF

Carers lacked training and clear guidance on how to manage unusual and difficult situations, specifically regarding an overheating client from a heater, leading to a fatal outcome.

Date 25 Jul 2016

56-day deadline 19 Sep 2016 est.

Responses identified 1 of 1

Community health care and emergency services related deaths

Coroner's concerns

AI summary

Carers lacked training and clear guidance on how to manage unusual and difficult situations, specifically regarding an overheating client from a heater, leading to a fatal outcome.

View full coroner's concerns

_ It is accepted that the circumstances were unusual and none of the carers were likely to have been trained what to do in such a situation. Indeed, it is accepted that they were placed in a difficult position, not turning the heater up would lead to the client cold during the night, turning it up with no one due in to review the situation led to an uncomfortable and ultimately fatal situation for Mrs Nesbitt.

(2) Nonetheless, it is difficult to say that this would be a completely unique situation and it is not impossible that other carers will be faced with similar situations in the future. What is a carer supposed to do in that situation? One supposes that the only potential remedy might be to include the circumstances of this case as a discussion in training of carers

Responses

1 respondent

Sheffield City Council Local Authority / Fire Service

PDF

Action Planned

The council has prepared documents including a case study overview and practical advice for support workers, which it intends to share as a training tool with internal and commissioning services, Sheffield Teaching Hospitals, social workers, care managers, and council quality and safeguarding teams. (AI summary)

View full response

Dear Mr Dorries write to confirm the response to the regulation 28 report received by Sheffield Council, Assessment and Care Management Services on July 2016. Following your conclusion at an inquest into the death of Mrs Marjorie Nesbitt on 14th June 20 you have informed us that during the course of the inguest matters were revealed givng rise to concern; The inquest resulted in a conclusion of misadventure although it was belief there was a risk that future deaths would occur unless action was taken It was saddening to read the circumstances of Mrs Nesbitt's death and although the circumstances were unusual we welcome your suggestions to prevent further deaths in the future_ You noted a potential remedy was to include the circumstances of this case as discussion in the training of carers To facilitate these discussions documents have been prepared and are included with this letter for your information. Enclosed is document (1) Improving Practice and Reducing Risk, which provides a format for a case study it gives an overview of the case and gives context to the lessons we have learnt. Also enclosed is document (2) Practical Advice, which gives practical advice for support workers and others with caring responsibilities_ It is the intention of Sheffield Council to share these documents within the week with our colleagues in, Internal provider services Commissioning services Sheffield teaching hospitals NHS foundation trust Social Workers and Care Managers Sheffield Council; Quality and Safeguarding October 2016 City City 25"h your City City

Sheffield City Council is making a recommendation that the above parties use the documents as a training tool and to provide information which informs those working in health and social care professions of the risks which are related to the content of the case_ It is sincerely hoped that by providing this information and advice to others we may be able to prevent deaths in the future_ If you _have any queries concerning the above, please do not hesitate to contact me on

Report sections

Investigation and inquest

On the 17th September 2015 commenced an investigation into the death of Mrs Marjorie Nesbitt (aged 97). The investigation concluded at the end of the inquest on 14th June 2016. The conclusion of the inquest was that Marjorie Nesbitt had died of hyperthermia in the presence of ischaemic heart disease and pulmonary emphysema with old age and frailty as contributing factors_ returned a conclusion of misadventure noting that Mrs Nesbitt had requested her carers t0 increase the power of a convector heater but that this then remained on overnight causing a very hot room_ Mrs Nesbitt's condition was such that she could not regulate her own body temperature_

Circumstances of the death

Marjorie Nesbitt lived on her own with carers attending four times a is no complaint about the conduct of the carers at any time On Friday, 11th September 2015 carers noted sparks within the vicinity of a wall socket where two items were plugged in: One was the power move to Mrs Nesbitt's bed, the other was an oil filled free-standing radiator which was generally the major regulator of temperature in the room_ The company providing the carers caused an electrician to attend almost immediately and it was noted that the socket was defective and that the plug to the oil filled radiator was partly melted. No doubt all of this would have been fixed in due course but the immediate action of the electrician was to say that the socket and in particular the oil filled radiator with its defective plug could not be used again until mended and checked. The carers, and indeed Mrs Nesbitt were keen to follow this advice. The only remaining heating device for the room was a fan heater which was away from the immediate area of the bed and was left during the on its lowest setting, providing a comfortable There day: day atmosphere However, at the time of the evening visit there was discussion between the carers and Mrs Nesbitt leading to the fan heater being turned up, most likely to its second setting out of three_ Unfortunately Nesbitt was bedbound, the fan heater was out of reach and there was not going to be a further visitor until the carers morning round: When the morning carers attended they found that the fan heater was still in the same position and that the room was extremely hot Mrs Nesbitt was in the last stages of life , still in her bed: All proper measures were taken by the carers in calling for the Emergency Services etc = but Mrs Nesbitt could not be saved: The inquest found that the medical cause of death was hyperthermia in the presence of ischaemic heart disease and pulmonary emphysema In simple terms the overheating of the room, with Mrs Nesbitt's inability to regulate her own body temperature through age and illness had taken her life_ It was noted that her old age and frailty were contributing factors _

Action should be taken

In my opinion action should be taken to prevent future deaths and believe your organisation have the power t0 take such action: In fairness, beyond inclusion of the case as a training tool cannot personally see an easy remedy:

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Report details

Reference: 2016-0263
Date of report: 25 July 2016
Coroner: Christopher Dorries
Coroner area: South Yorkshire (West)

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 19 Sep 2016 (estimated).

Sent to

Sheffield City Council

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.