Source · Prevention of Future Deaths

Christopher Royal

Ref: 2014-0354 Date: 30 Jul 2014 Coroner: Lydia Brown Area: Leicester City & South Leicestershire Responses identified: 1 / 1 View PDF

The nursing home had an unreliable patient observation system, expired First Aid certifications, staff incompetence in CPR, and concerns regarding care quality due to excessively long shifts.

Date 30 Jul 2014
56-day deadline 27 Sep 2014
Responses identified 1 of 1
Care Home Health related deaths

Coroner's concerns

AI summary
The nursing home had an unreliable patient observation system, expired First Aid certifications, staff incompetence in CPR, and concerns regarding care quality due to excessively long shifts.
View full coroner's concerns
1) Mr. Royal was on 15 minute observations. The observations were not carried out by a designated member of staff; there was no system in place; the recorded observations were unreliable and inaccurate; recordings were not made by the staff who had actually observed Mr. Royal. Consideration should be given to a more robust, safe and accountable observation system, and proper training and auditing to ensure this is in place and operating effectively.
2) Evidence was taken that the Matron did not have a valid First Aid Certificate at the time of this event; it had expired in 2011. There was evidence that the nursing home staff response to this medical emergency was inadequate and insufficient. One member of staff said although First Aid trained she did not feel competent to carry out CPR. First Aid training is essential in a Nursing Home environment, and there should be in place a proper system to ensure training is provided, updated, effective and understood. An annual system of review and/or appraisal may assist in the monitoring process and allow staff feedback and concerns reporting.

3) Matron said she regularly worked a 13.5 hour shift as it meant less travelling time as many staff lived a distance from the home. This length of shift may not be conducive to good health care and may have contributed to the poor care given that evening to Mr. Royal. Consideration should be given to whether shifts of this length are for the benefit of the residents or the staff, and if any perceived benefits outweigh any potential problems this type of shift pattern may create.

ACTION SHOULD BE TAKEN

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

Responses

1 respondent
Royal 2014 0354
26 Aug 2014 PDF
Action Taken

Following a review of observation policies, the organisation issued a new policy to nursing staff and created a new record sheet for nursing staff. The organisation also developed a more robust training matrix and added a clause to employment contracts about keeping training up-to-date. (AI summary)

View full response
Dear nodmg

Regulation 28; Response to repont; Re: Mr € J ROYAL We take note of the report in respect of the unreliable and inaccurate recordings which were made for 15 minute observation requirements In response to this we have; Reviewed our observation policy in line with matters highlighted (see appendix A, completed 1s August 2014). Issued policy to nursing staff (August 2014) Created new record sheet for nursing staff to complete at the commencement and conclusion of shift The sheet clearly identifies who is responsible for carrying out certain requirements and it places an onus on the nursing staff to review the sheet the observation requirements (paperwork) at timely intervals (see appendix B, implemented 1* August 2014). Completion of observation sheets allocation sheets are being monitored by our General Manager for audit purposes and to ensure that the new regime is being implemented in an accurate and effective manner. This is an ongoing process We take note of the report and evidence that Matron'$ First Aid Certificate had expired at the time of the event; In response to this we have; After the death of Mr Royal in January 2013,and upon finding at this time that Matron'$ first aid training had lapsed, we immediately reviewed our training system and the implementation of such, developed our skills matrix to highlight an overview of staff training: Since February 2013, we have developed more robust training matrix which focuses on some of the key training of staff within nursing environment: The matrix enclosed (appendix C) , shows our progress to date and shows that the majority of our nursing and care staff have (during the past 18 months), undertaken training in many mandatory courses This is an ongoing process and we enclose (appendix D) copy of our training plan which shows our program for this year. We will continue to monitor staff training records. As part of this development; we now also allocate staff to attend sessions as opposed to our previous process of open attendance requirements We have also added clause to employment contracts which makes requirement to keep training "in- date" and allows us to take further action ifthis is not the case_ We are now ensuring that all nursing/care staff receive training in key areas. To monitor the effectiveness of this we will be reviewing training sessions with staff to find out how effective the session has been and to find out if there are any remaining shortcomings_ From our findings we can arrange further training if needed, source an alternative provider or continue to implement if well received: We are commencing this program of monitoring and review with effect from 1" September 2014. and and and

We continue to offer extensive training to all staff (as per our training plan), whilst the completed training of staff is closely monitored though our skills matrix: Effectiveness of training is to be monitored by evaluation and feedback from course participants Working hours of staff will be monitored to ensure that arrangements benefit our residents as opposed to the requirements of staff members. Director Response and accompanying documents produced irectors of Barons Park Nursing Home Ltd.

Report sections

Investigation and inquest
On 28 – 30th July 2014 I commenced an investigation into the death of Christopher John Royal, 67 years. The investigation concluded at the end of the inquest on 30th July 2014. The conclusion of the inquest was Cause of death - 1a Aspiration of stomach contents 1b Ischaemic heart disease

Conclusion – Natural causes contributed to by neglect
Circumstances of the death
Mr. Royal was properly detained under a DOLS order, Mental Capacity Act 2005 which prevented him from leaving Baron’s Park Nursing Home. He suffered a cardiac event on 25 January 2013 and was found collapsed in his en-suite bathroom that evening. Staff attending to Mr. Royal from the Nursing Home but did not provide any, or any adequate First Aid. Paramedics were summoned but Mr. Royal was pronounced life extinct as CPR was unsuccessful.
Copies sent to
East Midlands Ambulance Service NHS TrustCoventry Social ServicesCare Quality Commission and the

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Report details

Reference
2014-0354
Date of report
30 July 2014
Coroner
Lydia Brown
Coroner area
Leicester City & South Leicestershire

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: 27 Sep 2014.

Sent to

Baron’s Park Nursing Home

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