Source · Prevention of Future Deaths

Peter Norman Nott

Ref: 2014-0229 Date: 28 Feb 2014 Coroner: Nicholas Graham Area: Oxfordshire Responses identified: 1 / 1 View PDF

Care home staff failed to perform adequate neurological observations following a patient's fall, relying on simple visual checks despite prolonged immobility and clear deterioration.

Date 28 Feb 2014

56-day deadline 25 Apr 2014 est.

Responses identified 1 of 1

Care Home Health related deaths

Coroner's concerns

AI summary

Care home staff failed to perform adequate neurological observations following a patient's fall, relying on simple visual checks despite prolonged immobility and clear deterioration.

View full coroner's concerns

In circumstances it is my statutory to report to you the matters of ccncern as follows Although staff at the care home were attentive t0 Dr Norman Nott after his fall;, and advice was sought from Dr Norman Nott's GP , was accepted in questioning that the trained staff should have undertaken neurological observations over and above a simple visual examination. The need to undertake further examination was heightened when the length of time Dr Norman Nott remained lying down (although conscious) and certainly as this time extended into the afternoon: recommend that Rush Court Nursing Home review their procedures for attending on a patient after & fall (whether conscious or not) in order to identify the appropriate level of examination and nursing attention required_ When Dr Norman Nott arrived at hospital the Emergency department undertook

Responses

1 respondent

Elizabeth Finn Homes

16 May 2014 PDF

Action Taken

Rush Court care home has reviewed its policies and procedures when dealing with a resident who has experienced an unwitnessed fall. Neurological observations will commence using the Glasgow Coma Scale and be incorporated into resident care plans; only a registered nurse or person in charge can handover clinical information to paramedics. (AI summary)

View full response

Dear Mr Graham; write in response t0 your report dated 28h February 2014, regarding the circumstances surrounding the death of Dr Peter Nott; a resident at Rush Court care home, The report highlights some concerns that were discussed at the inquest and the organisation's duty to respond with an improvement plan within the timescale set. For clarity | will deal with each raised in turn: Concern One: recommend that Rush Court Nursing Home review their procedures for attending on a patient after a fall (whether conscious or not) in order to identify the appropriate level of examination and nursing attention required. The organisation has reviewed its polices and procedures when dealing with a resident who has experienced an unwitnessed fall_ This procedure will be cascaded to all clinical staff with instructions that should a resident fall and it is unwitnessed then nursing staff or the person in charge of a residential home, should commence neurological observations These will be recorded using the Glasgow Coma Scale and incorporated into a resident's care plan This procedure will be reinforced during staff meetings and any individual training needs will be monitored through the supervision, learning and development programme: Basic competencies for head injury care will be reviewed with all clinical staff and the person in charge of our residential home_ The timescale for this action to be completed is Ist April 2014. Concern Two: Rush Court Nursing Home review the information provide to paramedics attending and the procedures in place to ensure the accuracy of the information can be passed to paramedical staff attending the home_ Procedures have been reviewed with reference to information given to paramedics attending the home: The procedure states that only a Registered Nurse or person in charge of the home must hand over clinical information to the paramedic team. This is to be clear and concise, detailing observations and clinical judgement where appropriate. This will then be recorded clearly in the resident's care plan for future ELIZABETH FINN HOMES LIMITED Hythe House, 200 Shepherds Bush Road, London W6 ZNL Tel: 020 8834 9200 Fax: 020 8834 9299 Top 700 Registered in England and Wales Number: 5225008 enquiries@efhlcouk wwwefhl co uk Organisalion point they

reference. This information will be given to staff during staff meetings and all staff will sign as per policy to confirm they have agreed to and understood the procedure The timescale for this action to be completed is 1st April 2014. Elizabeth Finn Homes strives to offer quality clinical care to all of our residents and to review policies and procedures on an annual basis to ensure best practice is maintained. We have welcomed your advice upon how to further improve our policies and procedures and hope that this action will help to improve our practice.

Report sections

Investigation and inquest

On 9 September 2013 an investigation commenced into the death of Peter Norman Nott;, who was 75 years old. The investigation concluded at the end of the inquest on 26 February 2014. A short form conclusion of accidental death was recorded_ Dr Norman Nott had fallen in his room at Rush Court Nursing Home causing injury to his head_ The fall occurred around 10.30 hours but he was not taken to the hospital until 18.57 hours that evening: He succumbed on 8 September 2013. The medical cause of death was recorded as; 1(a) Subdural haemorrhage 1(b) Parkinson's disease

Circumstances of the death

Dr Peter Norman Nott had a complex medical history of Parkinson's decease with Shy-Drager syndrome (severe postural hypertension) with Dementia. He was assessed as being at very high risk of falls. Although the nursing home had undertaken detailed assessments to address Dr Norman Nott's propensity for falling; there were numerous incidents of falls at the home_ As indicated, on the morning of 2 September 2013 Dr Norman Nott experienced an unwitnessed fall in his room at the nursing home He was attended by nursing home staff and was conscious_ He spent the next two hours Iying down (which was not uncommon) until he was hoisted onto the bed where he remained and was nursed regularly checked Also the GP was called and suggested that he be closely monitored At 17.45 his condition deteriorated and an ambulance was called which took to hospital at 18.57 hours The hospital took & CT scan and in view of his condition considered that surgical intervention was futile. He sadly passed away on 8 September 2013 at 20.00 hours_ and hours him

Action should be taken

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

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Report details

Reference: 2014-0229
Date of report: 28 February 2014
Coroner: Nicholas Graham
Coroner area: Oxfordshire

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 Apr 2014 (estimated).

Sent to

Rush Court Nursing Home

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.