Source · Prevention of Future Deaths

Joan Mary Jones

Ref: 2013-0234 Date: 20 Sep 2013 Coroner: Catherine Mason Area: Leicester City and South Leicestershire Responses identified: 1 / 1 View PDF

Care home staff failed to escalate a patient's deteriorating condition and provide complete information to health professionals, resulting in inadequate care and putting the patient at risk.

Date 20 Sep 2013

56-day deadline 24 Mar 2014 est.

Responses identified 1 of 1

Care Home Health related deaths

Coroner's concerns

AI summary

Care home staff failed to escalate a patient's deteriorating condition and provide complete information to health professionals, resulting in inadequate care and putting the patient at risk.

View full coroner's concerns

In Ihe circumstances it is my statutory duty t0 report t0 you: The staff did not escalate Mrs Jones" care when they should have done The staff did not communicate all that was known t0 them and therefore attending heallh care professionals were unable t0 make fully informed decisions (3) Due to the lack of communication; an appropriate package of care was not put in place for Mrs Jones These omissions (failure t0 escalate and the lack of communication with other attending health care professionals) together or alone could in future circumstances cause or contribute t0 death: Action SHOULD BE TAKEN In my opinion action should be taken t0 prevent future deaths and believe you have the power t0 take such action.

Responses

1 respondent

The Manor

11 Nov 2013 PDF

Action Taken

Following an inquest, the care home sent a memo to unit leads emphasizing communication protocols with families and healthcare professionals after GP visits. They also contacted the family and engaged a consultant to arrange a meeting to address outstanding questions. (AI summary)

View full response

Dear Coroner,

Ref Mrs Joan Mary Jones On 1st October 2012 Mrs Jones passed away at the Manor Care Home in Leicester. After the death of Mrs Jones an inquest was held on 18th September 2013. The verdict was a narrative one, with directive for the home's manager to take further action to ensure clear lines of communication after and out of hours GP visit. Also the home was to contact the family to meet up and answer any outstanding questions they had. On 19th September 2013 a memo was sent to all the unit leads to ensure that following any input from GP's and out of hours nurses, doctors the family must be contacted, that the communication sheet must be completed following any discussions, involvement with any health care professionals. That these communications sheets must be shared with any health care professionals and completed after each visit by health care professionals. These visits must be communicated to the family. It was also agreed that the home's manager would meet up with the family to discuss any unanswered questions. We have written to on 20th September 2013 and 6th November2013, second time recorded deliver to ensure receipt of the letter. Since we have not had any response from we have asked our independent care consultant, BKR Care Consultancy (BKRCC), to write and offer to arrange a meeting to discuss any questions with the family. BKRCC will be writing to by 18 Nov 2013. This will be sent recorded delivery. Cc:

78-80 Lutterworth Road ,Aylestone, Leicester, LE2 8PG Tel: 0116 2990225/229,Fax: 0116 2990257, E-mail themanorcarehome@hotmail.com

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20t h September 2013 Dear , RE: Late Mrs Jones I write further to the coroner's inquest that was held on the 18t h September 2013. I was ade aware at the inquest that you had some concerns about the care that your mother Late Mrs. Jones received from the home, and would like to arrange a meeting so that we can discuss these and an internal investigation can commence. Please contact me on the numbers below or my mobile so that an appointment can be arranged at your convenience to discuss these concerns. I will look forward to hearing from you soon.

Manager 78-80 Lutterworth Road ,Aylestone, Leicester, LE2 BPG Tel: 0116 2990225/229,Fax: 0116 2990257, E-mail themanorcarehome@hotmail.com

Report sections

Investigation and inquest

On g" October 2012 commenced an investigation into the death of Joan Mary Jones: The investigation concluded at the end of the inquest on 18" September 2013. The conclusion of the inquest was that the cause of death was Bilateral bronchopneumonia due t0 locally advanced adenocarcinoma of the large bowe and Alzhelmer $ dementia; A narrative conclusion was recorded as follows: On the 23" September 2012 Mrs Jones became unwell and was seen by an out of hours doctor who diagnosed viral Infection; No further concerns were raised until the 30' September 2012 when she became unresponsive following an episode of aspiration the previous day: Again an out of hours practitioner attended Mrs Jones thereafter continued t0 deteriorate and she died on the 1" October 2012 at The Manor and Residential Home Leicester: Medical opinion is that when Mrs Jones initial illness had not showed signs of improvement after 2 t0 3 days her General Practitioner should have been notified and it is likely that antibiotics would have been prescribed This did not happen As a result there was missed opportunity t0 treat However; medical evidence is that it is unclear whether the outcome would have been different

Circumstances of the death

Mrs Jones was a resident at-Manor and Residential Home; Leicester and was known t0 have Alzheimer s dementia An out of hours doctor saw her on the 23"0 September 2012 because the professionals caring for her were concerned about her being unwell; The doctor found her t0 have runny nose and slight cough AIl vital signs were within normal range and viral upper respiratory tract infection was diagnosed. Medication was not considered necessary and advice was given t0 encourage fluids and report any deterioration or further concerns Mrs Jones continued t0 be cared for at Ihe Home On the 30' September those caring for Mrs Jones sought assistance from an out of hours advanced nurse practitioner When he attended he observed that Mrs Jones had cold Iike symptoms and again considered them t0 be viral in nature He noted low blood pressure but was not concerned with it of itself However; evidence revealed that he was not told of the doctor $ visit the week before nor of the vital signs recorded at that stage In addilion; he was not infirmed of the aspiration; He said if he had he thought it was Iikely that he would have made arrangements for Mrs Jones t0 be admitted t0 hospital rather than instruct that she should remain at the Home A Doctor from the practice that Mrs Jones was registered at, that she not necessarily have admitted Mrs Jones t0 hospita had she been faced with the same situation, but gave evidence that when Mrs Jones had not showed signs of improvement after 2 t0 3 days following the medical attendance on the 23" September 2012, she would have expected the Home to have contacted the practice and doctor would have The said would visited: Furthermore, she stated that in her professional opinion; with the knowledge of Mrs Jones' dementia and Ihe care home setting antibiotics would have been prescribed; However she was not able t0 say whether on balance of probabilities the outcome would have been different However; she was clear in saying that there was missed opportunity t0 treat and communicate with Mrs Jones' tamily and discuss an advanced care plan

Inquest conclusion

On the 23" September 2012 Mrs Jones became unwell and was seen by an out of hours doctor who diagnosed viral Infection; No further concerns were raised until the 30' September 2012 when she became unresponsive following an episode of aspiration the previous day: Again an out of hours practitioner attended Mrs Jones thereafter continued t0 deteriorate and she died on the 1" October 2012 at The Manor and Residential Home Leicester: Medical opinion is that when Mrs Jones initial illness had not showed signs of improvement after 2 t0 3 days her General Practitioner should have been notified and it is likely that antibiotics would have been prescribed This did not happen As a result there was missed opportunity t0 treat However; medical evidence is that it is unclear whether the outcome would have been different

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Shared signals

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Report details

Reference: 2013-0234
Date of report: 20 September 2013
Coroner: Catherine Mason
Coroner area: Leicester City and 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: 24 Mar 2014 (estimated).

Sent to

Manor Residential and Nursing Care Home

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.