Source · Prevention of Future Deaths

Peter Furness

Ref: 2015-0398 Date: 5 Oct 2015 Coroner: John Gittins Area: North Wales (East and Central) 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe care home lacks a documented process for escalating incidents or concerns to trigger multi-disciplinary team meetings that review risk assessments and care plans for vulnerable residents.

Date 5 Oct 2015

56-day deadline 30 Nov 2015 est. estimated from the report date

Responses identified 1 of 1

Care Home Health related deaths

Coroner's concerns

AI summary

The care home lacks a documented process for escalating incidents or concerns to trigger multi-disciplinary team meetings that review risk assessments and care plans for vulnerable residents.

View full coroner's concerns

_ _ The Registered Individual responsible for the care home and the current Manager both acknowledged that within current systems and protocols operating at the home, there is no documented process by which incidents or concerns are escalated s0 as to result in a multi disciplinary team meeting aimed at reviewing the risk assessments and care plan relating to the vulnerable person within their care. doing and

Responses

1 respondent

Nant Y Gaer Hall

PDF

AI-classified response stance Action Taken

AI-generated response summary

• Nant Y Gaer Hall implemented a new alert system for escalating changes in residents' conditions and behaviours. • The new system includes a clear process, policy documents, flow charts, forms, and handover sheets, with all staff having received training and signed to confirm understanding. • Two red alert files were developed, and posters were placed to inform families and visitors about the new system.

View full response

Dear Mr John Gittins, In order to fully comply with the regulation 28 we have addressed our alert system_ This will alert all staff to changes in our residents' physical conditions and their behaviours. The new system is self- explanatory (please see copy's sent initially a simple alert form is completed by whoever first identifies the concern; this is then evaluated by the qualified nurse in and is escalated by the nurse (please see copies sent): This process gives clear instruction throughout the alert process and will inevitably reduce risk and involve the wider disciplinary team immediately if necessary. This remains a work in progress and it will be evaluated and amended to what is working and what is not: All staff have undergone a training session and undergone a supervision on the changes. The new system of raising an alert is supported by posters placed around the building for family's and visitors to be aware of how we deal with concerns and alerts. (Incidents and accidents are also covered within the alert process and form part of the new policy): have together policy and alert/incident processes and have included flow charts for all staff, alert and incident forms, new handover sheets with 7 follow up and a new alert poster All staff have signed to say they have read and understood the policy and alert procedure: Two red alerts files have been developed for both sides of the home so that staff can easily report and follow up on all concerns. Please contact me if you require any further information:

Report sections

Investigation and inquest

On 16th of October 2014 commenced an investigation into the death of Peter Scott Furness then aged sixty six. The investigation concluded at the end of the inquest on the 30h of September 2015. The conclusion of the inquest was Accidental Death; the medical cause of death being 1(a) Choking on a Latex Glove (b) Dementia_

Circumstances of the death

The Deceased, who had been diagnosed with Frontal Lobe Dementia, was a resident at the Nursing Home which provides care for persons with dementia He was known to be at risk of placing non-edible items in his mouth and had been observed so on a number of occasions_ Although risk assessments had been undertaken he collapsed on the 13th of October 2014 and was verified dead at the home at 12.32 hours A Post Mortem established that he had choked on a latex glove two further gloves were found in his stomach which had been ingested previously.

Action should be taken

In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action.

Similar PFD reports

Shared signals

Report details

Reference: 2015-0398
Date of report: 5 October 2015
Coroner: John Gittins
Coroner area: North Wales (East and Central)

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: 30 Nov 2015 (estimated from the report date).

Sent to

Nant y Gaer Hall Nursing Home

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.