Edwin Thompson

A The seeking of medical advice and assistance. There is a need to draft and disseminate to all care staff a clear, simple and concise directive to care home staff to seek medical advice or assistance in respect of residents presenting with pain, particularly of a cardiac nature without delay. Staff with no medical qualification must not seek to speculate as to possible causes of symptoms and should not seek to medicate ( unless otherwise previously prescribed by a Medical Practitioner) or prescribe “remedies” of no or no known worth to anyone in their care. B As to Training Training in the practices and protocols within the establishment should be formalised, regularised and directed as a personalised package to all staff. It should be the subject of planned periodic review and revision throughout the year and an integral part of the established annual appraisal of staff members and their performance. The quality and effectiveness of in house training provision should be an integral and essential element in and of the periodic appraisal of management performance. C As to record keeping The accurate recording of incidents affecting the care and management of residents is an essential tool in keeping staff informed of the needs of residents in order that the staff can be better able to react respond and plan for the essential needs of residents. The quality of the recording of notes must be evaluated by management on their regular reviews of residents care notes and staff must be made aware in a timely fashion of any shortcomings in the notes and their content. Assistance to improve in the recording of notes must be given an urgent priority in any training needs and recognised as a significant performance issue if there is consistent failure to adhere to the expected standard. Ultimately and aspirationally a computer based system of record keeping would be the preferred option, but the lesson of effective record keeping in whatever format, has to be reinforced by regular and effective file checks by Managers. Action Should be Taken

In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. Your Response

You are under a duty to respond to this report within 56 days of the date of this report, namely by 9th 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 why no action is proposed. Copies & Publication

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons {NAMES} {and to the Local Safe-Guarding board (where the deceased was under 18)}. I have also sent it to the {NAMED PERSON} who may find it useful or of interest.

I am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Date: 22nd December 2014 {Signature}

Senior Coroner – Gateshead & South Tyneside