Source · Prevention of Future Deaths

Anne Scott

Ref: 2016-0024 Date: 12 Jan 2016 Coroner: Elizabeth Carlyon Area: Cornwall Responses identified: 0 / 1 View PDF

Community care providers lacked training to correctly interpret and act upon data from health monitoring devices, and county-wide safeguarding recommendations for such training remain unconfirmed.

Date 12 Jan 2016
56-day deadline 8 Mar 2016 est.
Responses identified 0 of 1
Community health care and emergency services related deaths

Coroner's concerns

AI summary
Community care providers lacked training to correctly interpret and act upon data from health monitoring devices, and county-wide safeguarding recommendations for such training remain unconfirmed.
View full coroner's concerns
In (hese circumslances it is my stalutory duty to report to you: That special health monitoring devices are being used t0 monitor heallh conditions in palients who are receiving care in (he community. However the care providers do nolt have the necessary training to be able to understand how the device operates, the information it provides and appropriate action to take, dependent on the information from Ihe device, in conjunction with other observations_ At the inquest we heard that this matter was referred t0 (he Safeguarding Adults Board and some learning points had been identified for (he care providers. In particular, was known (hat Mrs Scotl was prone lo urinary tracl infeclions and whilst suffering from these infections Mrs Scolt was known to become confused. A special health monitoring device (Telehealth) was in place The care provider failed to identify (he urinary tract infection prior to admission Thesewere addressed in Ihe Adult Saleguarding Board and

Tearning (Social Worker) (Care Provider Representative) confirmed changes were being considered but could not confirm if recommendations were being implemented. Both the representative of the Safeguarding Adults Board and the care provider consider that a Regulalion 28 report would assist in embedding the Safeguarding Adults Board recommendalions which had counlywide implications_ AcTION SHOULD BE TAKEN In my opinion action should be taken to prevent future dealhs and believe the Cornwall and Isles of Scilly Safeguarding Adulls Board has the power to take such action: To consider recommendalions oullined by (he local Safeguarding Adulls Board in this case are considered countywide in particular wilh (he training and use of Teleheallh.

Report sections

Investigation and inquest
The investigation into the death of Anne Shirley Scott was opened on the 2nd October 2014 It was concluded by way of an inquest on the 3rd March 2015. The verdict was accidental death the causes of death were 1(a) Renal Failure 1(b) Rhabdomyolysis (clinically) & 1(c) Un-witnessed fall:
Circumstances of the death
Anne Scott had an unwilnessed fall over nighl and was found by her carer in the morning of the 29th August 2014 crouched over in a cupboard at her home address_ She was admitted to the Royal Cornwall Hospital, Treliske, Truro and diagnosed with acule kidney injury secondary (o Rhabdomyolysis_ She had significant bruising to her legs. Despile being started o haemodialysis, her renal function deleriorated and she was discharged on 16th September to her daughter's house for end of life care and she died on 19th September 2014. Mrs Scott was prone to urinary tract infections (UTI's) during which she became confused and vulnerable to falls_ A "Teleheath" monitoring device was put in place; however; the care provider did not appreciate the information provided by (he device and acl on it

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Report details

Reference
2016-0024
Date of report
12 January 2016
Coroner
Elizabeth Carlyon
Coroner area
Cornwall

Responses identified

Responses identified 0 of 1
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 8 Mar 2016 (estimated).

Sent to

Cornwall and Isles of Scilly Safeguarding Adults Board

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