Source · Prevention of Future Deaths

Jack Lynn

Ref: 2014-0066 Date: 18 Feb 2014 Coroner: Tony Brown Area: North Northumberland 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner noted the absence of a medication communication sheet at Mr Lynn's home, which prevented reliable checks on medication, and that a 15-minute visit did not include a check on his safety or well-being.

Date 18 Feb 2014

56-day deadline 15 Apr 2014 est. estimated from the report date

Responses identified 1 of 1

Community health care and emergency services related deaths

Coroner's concerns

AI summary

The coroner noted the absence of a medication communication sheet at Mr Lynn's home, which prevented reliable checks on medication, and that a 15-minute visit did not include a check on his safety or well-being.

View full coroner's concerns

Arrangements put in place for daily prompting with medication did not include keeping a medication communication sheet at Mr Lynn’s home address as a continuous record of his medications. This would have allowed for a more reliable check by visiting carers or family members as it would have clearly indicated whether medications were being taken regularly.

The absence of any check on Mr Lynn’s safety or well being during the allocated 15 minute visit on the morning of 15th October 2013 exposed Mr Lynn to potential risk, albeit that the sudden cardiac event which occurred could not have been prevented. The risk was present, nonetheless, and creates a risk that future deaths might occur if action is not taken.

Responses

1 respondent

Nightingales Home Help Service

Other

PDF

AI-classified response stance Action Taken

AI-generated response summary

• The service stated it would encourage clients to use medication charts in their communication folders and advise that this is company policy for carers involved in medication services. • All staff were advised to review the medication policy, and 22 staff members attended a Safe Handling of Medication course provided by an independent trainer. • The staff member involved received a verbal warning for not following company procedure and was advised on future client checks.

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REPORT FOLLOWING REGULATION 28: REPORT TO PREVENT FUTURE DEATHS 1 CORONER Brown LLM H M Senior Coroner North Northumberland 2 CLIENT Jack Basil Lynn 3 MATTERS OF CONCERN RAISED BY SENIOR CORONER Arrangements put in place for prompting with medication did not include keeping a medication communication sheet at Mr Lynn's home address as a continuous record of his medications, This would have allowed for a more reliable check by visiting carers or family members as it would have clearly indicated whether medications were being taken regularly. The absence of any check on Mr Lynn's safety or well being during the allocated 15 minute visit on the morning of 15t October 2013 exposed Mr Lynn to potential risk, albeit that the sudden cardiac event which occurred could not have been prevented, The risk was present, nonetheless, and creates a risk that future deaths might occur if action is not taken. ACTION TAKEN FOLLOWING INCIDENT We will encourage all of our clients to have medication charts in their communication folder and in the case of not wishing to have one we will advise that if a carer is involved in any service concerning medication it is Company policy to have them in the folder. We have advised all staff to make themselves re-aware of our medication policy in their handbook and to actively ask any questions that arise We have had an Independent Trainer provide Safe Handling of Medication course in October 2013 to which twenty two staff attended_
5. ACTION TAKEN TO EMPLOYEE INVOLVED IN INCIDENT The staff member was given a verbal warning in disciplinary meeting for not following Company procedure in not physically checking her client and his medication prompt and advised that in the future she should always physically check on a client unless we, Management; have their written word not to and a set procedure is detailed for the individual client to carry out our service to their wishes 6 DATE February 2014. DIRECTOR OF NIGHTINGALES HOME HELP SERVICE E0 jovd T6sE0E6831D LZ:0T pioz/E0/80 Tony daily 27th

Report sections

Investigation and inquest

On 17th October 2013 I commenced an investigation into the death of Jack Basil Lynn, age 86 years. The investigation concluded at the end of the inquest on 14th February 2014. The conclusion of the inquest was that Jack Basil Lynn died from natural causes, the medical cause of death being:-

1a Haemopericardium 1b Ruptured Acute Myocardial Infarction 1c Coronary Artery Thrombus

Circumstances of the death

Jack Basil Lynn lived alone at his home address. Staff from care providers Nightingales Home Help Service attended Mr Lynn on a daily basis morning and night, to ensure he was prompted to take his medication and to check on his well being. A carer who visited Mr Lynn on the 15th October 2013 for a planned 15 minute visit entered the house with a key. The carer observed that Mr Lynn was not downstairs when she called and assumed that he must have gone back to bed. She believed that Mr Lynn had taken his medication for that morning by looking at a plate on a table where he normally put that morning’s tablet, but it was probable in the circumstances that he had not taken his medication on that day. No further checks on Mr Lynn were made by the carer at that time to ensure his well being before she closed the door and left the property. Later that evening the same carer returned to the property and as Mr Lynn was still not downstairs she went upstairs to check on him. Mr Lynn was found unresponsive on the bathroom floor. Paramedics were called but could not assist and Mr Lynn’s death was pronounced at 20.03 hours.

Copies sent to

Care Inspectorate

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Report details

Reference: 2014-0066
Date of report: 18 February 2014
Coroner: Tony Brown
Coroner area: North Northumberland

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: 15 Apr 2014 (estimated from the report date).

Sent to

Nightingale Home Help Service

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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