Source · Prevention of Future Deaths
George Hulme
Ref: 2015-0016
Date: 8 Jan 2015
Coroner: Christopher Murray
Area: Manchester (South)
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryAgency staff lacked information and adequate induction to identify residents, resulting in an incorrect file retrieval and potentially inappropriate treatment. Resident rooms were also not clearly marked, which could lead to identification confusion during emergencies.
Date
8 Jan 2015
56-day deadline
5 Mar 2015 est.
estimated from the report date
Responses identified
0 of 1
Coroner's concerns
Agency staff lacked information and adequate induction to identify residents, resulting in an incorrect file retrieval and potentially inappropriate treatment. Resident rooms were also not clearly marked, which could lead to identification confusion during emergencies.
View full coroner's concerns
1) Agency members of staff on duty did not have any information to assist with the identification of residents. Whilst a system of cards is supposed to operate within the home, the agency staff on duty had no such card to identify residents_ ; J June key
2) Agency members of staff are supposed to have an induction and tour of the home upon their first visit. This did not take place adequately to sufficiently familiarise the staff with the residents or any method of correctly identifying residents_
3) An incorrect file was retrieved resulting in potentially inappropriate treatment of an unconscious resident.
4) The residents rooms are not clearly marked internally or externally to denote who resides in the room giving rise to confusion over identification in the event of emergency treatment being required by an unconscious resident attended to by staff or medical practitioners not familiar with their identity: ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 of the date of this report; namely by 12th March 2015. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action: Otherwise you must explain no action is proposed_
2) Agency members of staff are supposed to have an induction and tour of the home upon their first visit. This did not take place adequately to sufficiently familiarise the staff with the residents or any method of correctly identifying residents_
3) An incorrect file was retrieved resulting in potentially inappropriate treatment of an unconscious resident.
4) The residents rooms are not clearly marked internally or externally to denote who resides in the room giving rise to confusion over identification in the event of emergency treatment being required by an unconscious resident attended to by staff or medical practitioners not familiar with their identity: ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 of the date of this report; namely by 12th March 2015. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action: Otherwise you must explain no action is proposed_
Similar PFD reports
Report details
- Reference
- 2015-0016
- Date of report
- 8 January 2015
- Coroner
- Christopher Murray
- Coroner area
- Manchester (South)
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: 5 Mar 2015 (estimated from the report date).
Sent to
- Bamford Grange Nursing Home