Source · Prevention of Future Deaths

John Shelley

Ref: 2014-0352 Date: 31 Jul 2014 Coroner: Jonathan Layton Area: Carmarthenshire & Pembrokeshire Responses identified: 1 / 1 View PDF

The inquest revealed unstated circumstances that pose a continued risk of future deaths if action is not taken.

Date 31 Jul 2014
56-day deadline 25 Sep 2014 est.
Responses identified 1 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
The inquest revealed unstated circumstances that pose a continued risk of future deaths if action is not taken.

Responses

1 respondent
University Health Board
31 Jul 2014 PDF
Action Taken

Since the event, all staff in the residential units have been trained in Basic Life Support. The University Health Board is evaluating options for training healthcare support staff in managing life-threatening conditions. (AI summary)

View full response
Dear Sir Rei_Inquest regarding the death of John Keith William Shelley I write further to your letter of 31st July 2014, pursuant to Regulation 28 of the Coroners (Investigations) Regulations 2013. In terms of the issues raised in your letter we believe it would assist to differentiate between professionally qualified staff and support workers Firstly, we have programs in place to train all our professionally qualified staff in Immediate Life Support/Basic Life Support training which comprises the recognition and response to the acutely unwell patient and includes response to cardiac arrest_ on to second group of staff, our Healthcare Support Workers, who comprise the majority of the staff employed in this residential unit; they have not routinely been trained in Basic Life Support or "first aid". Although if this had been requested and subject to capacity, this could be undertaken: This has been because the focus of the Simulation & Resuscitation Team has been to deliver training directly to all clinical staff annually within the Health Board_ Risk assessments approved by the Health Board Resuscitation Committee have resulted in prioritising the training to high risk areas. However, since this tragic event all the staff in the residential units have been trained in Basic Life Support. 3wfad echyd Pritysgol Hywel Daa yw gweitnredol Bwrdd Iechyd Lleol Prifysgcl Hywel Dda Hywe Dda University Health Board is the operational name oi Hywel Dda University Local Health Board Mae Bwrdd lechyd Prifysgol Hywel Dda yn amgylchead di-fwg Hywel Daa University Health Board operates smcke free envircniert Moving the

In terms of moving further forwards, we have also looked at other options which may be available for healthcare support staff, where this would be appropriate We are evaluating options for training these staff groups to target "life threatening conditions We feel that a specifically targeted approach to life threatening conditions will provide the best type cover and will be more specific than a generalised first aid course: This course will include recognition & response to life threatening conditions i.e heart attack, choking, serious bleeding including cardiac arrest and is recognised by British Heart Foundation_ We will be taking a risk based approach to determine which staff will require thls level of tralning, which will include if will be working unsupervised without the direct support of trained clinical staff_ Should you have any queries please don't hesitate to contact me_

Report sections

Investigation and inquest
On 18th July 2013 I commenced an investigation into the death of John Keith William Shelley then aged 68. The investigation concluded at the end of the inquest on 31 July 2014. The conclusion of the inquest was a narrative conclusion namely that the deceased had died on the 14th July 2103 from lobar pneumonia resulting from the ingestion of fairy liquid. The medical cause of death was: 1(a) lobar pneumonia
Circumstances of the death
(1) John Keith William Shelley who had suffered brain injury at birth was wholly dependent upon the care of others. (2) Following an assessment of his needs he was accommodated in a residential care home by the Health Board. (3) Given his propensity to drink any liquids, certain steps were taken to try to prevent Mr Shelley consuming harmful substances. (4) Despite this he was able to obtain and consume a quantity of fairy liquid from a bottle placed near to the kitchen window. (5) Having consumed the fairy liquid he quickly became ill. (6) There was a significant delay before advice was sought. The full extent of Mr Shelley’s illness was not adequately communicated to the person from whom advice was sought. Thus an inadequate assessment of the situation was made. (7) Despite clear signs of Mr Shelley’s deteriorating health no contact was made with emergency services for some time.

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Report details

Reference
2014-0352
Date of report
31 July 2014
Coroner
Jonathan Layton
Coroner area
Carmarthenshire & Pembrokeshire

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: 25 Sep 2014 (estimated).

Sent to

Hywel Dda University Health Board

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