Gwendoline Clarke

PRIVATE & CONFIDENTIAL Pine Tree Court Response to Coroner's Report Introduction respond to the HM Coroner'$ Report dated 8.6.16 in relation to the death of Gwendoline Betty Clark who refers to the cause of death as respiratory failure, sepsis, pancreatitis, diabetes and bilateral femoral fractures The Coroner refers tq concerns in point 4 in order to prevent possible future deaths, the matters are a5 follows: Reporting of the injury that was sustained A 12 hour delay in escalation and safeguarding matters in relation to the allegations that a member of staff had hurt her. Background and Facts The lady concerned had a number of long term conditions including mental health issues resulting in paranoia and there was a history of regular accusations made against staff as well as others. She also took medication that would of course affect the bone structure: Betty moved aroundthe home freely, she had suffered previous unwitnessed falls due to her level of independence_ There is no reference that any staff were indeed aware of any falls or occurrences that could have resulted in such injury, this was confirmed by the investigation nor was there any person on duty that Betty had described who had allegedly caused the harm_ The circumstances remain that there was a delay in requesting aid, a delay in the attendance of the emergency services and delays in reporting the safeguarding matter at the weekend/bank holiday period when the office was closed. This was clearly outside of these times (office hours Monday Friday 8-5.30pm) hence the stated of 12 hours_ Actions An analysis of the report and taking on board the concerns raised through the process, the following actions are necessary: Action By Who/When Evaluation Re-enforce the safeguarding policy, share with all July 2016 Audit PLJ Within hore staff and use this as supervision; include out of August hours reporting process and the manager absence, check staff awareness and knowledge of this process_ This also includes an update of the Job Description (RN) Include the admission process under general PU Document screening fok our clients, an assessment to determine June 2016 Key being police delay Copv

those more at risk of fractures due to medical problems and lack of sunlight Audit of Care Include relevant signs/symptoms within the monthly Plan health chedk check Quality File each month re use of accident log Re-enforce the home' $ protocols for unwitnessed Training Record accidents ahd remind staff regarding examination, Julv 2016 Analysis clinical judgement and pain management see enc pain chart Plan training and supervision refresher first aid Certification particularlyto focus on fracture detection
5.7.16 Review thelhome's management and on-call process Complete New registered both home Manager and regional support manager manager have now changed pending Intensify thE abuse audit and surveys to complete Ito check re each month for a 12 month period quality file compliance vii Utilise the company escalation tool in order to Complete and to check highlight the practise of the ambulance service Ongoing during care plan particularlylin relation to handling techniques check audit Sept 16 use of SBAR viii Conduct a reflective piece, include qualified staff and Complete 0 hold on use for NMC revalidation June 2016 file and distribute to nurses (own copy) Refer the issue for external investigation (Bob Taylor) July 2016 Personnel file and review possible breeches in conduct as well as NMC code Explore thelout of hours safeguarding service within June 2016 Poster available Gloucester_and circulate details with the home