Gabbandco
Disputed
The care home disputes that there was a communication breakdown between the care home, district nurses, and the out-of-hours GP service, asserting that communication breakdown was between district nurses and the GP out of hours service. (AI summary)
View full response
Dear Ms Hunt Terence O'Connell (deceased) We represent the proprietor of Monkstone House Residential Home of Locks Common, Porthcawl, CF36 3HU and have been asked by them to respond to your letter dated 28th August 2013 in which you required a response to your Regulation 28 Report to Prevent Future Deaths: We note that in paragraph 5 you have raised three specific and particular concerns and you have asked for a response to each of these, which we will now deal with as below. Communication Failure You have indicated that in your view there was a communication breakdown between the care home, district nurses and the out of hours GP service on 3r May 2013 resulting in Mr O'Connell not been seen by any clinical staff. With respect; our clients do not accept that there was a communication problem between the three parties who you have indentified. The communication breakdown (assuming that such was the case) was between the district nurses and the GP out of hours service. On 3r our client's staff contacted the district nurses on three separate occasions during the evening_ There was also series of conversations between the out of hours doctor and district nurses which our clients have been made aware of. Our client's staff alsospoke to thefamily of the late Mr O'Connell on three separate occasions (Mr O'Connell's son in law) was the person who was spoken to and there are phone records available to prove this: RECEIVED 15 OCT 2013 Partners Consultants Associates Old Bank House Beaufort Street Crickhowell Powys NP8 IAD Tel 01873 810629 Fax 01873 810485 DX 100751 CRICKHOWELL Email crickhowell gabb.co.uk (not for servicer wwWgabb couk AuthoristdunoiCquiated dyimc Sclicmors Acqulation Zuimort - Dio *7700 the May
N The last phone call to was at 12.40am. During the course of this telephone conversation a senior member of staff at Monkstone House informed that neither the district nurses nor the out of hours GP was going to attend to Mr O'Connell at Monkstone House did not want to arrange for Mr O'Connell to go to A&E: linformed the member of staff that he had spoken to the GP out of hours and he was happy for Mr OConnell to remain at Monkstone House and he would ring in the morning to see what progress had been made. Staff at Monkstone continued to monitor Mr O'Connell throughout the night and there is documentation available to confimm this. No concerns were noted during this time Notwithstanding the Morikstone House policy has now been changed with regard to clinical assessment: The effect of this is that if a health professional (either district nurse or GP) will not attend Monkstone House within one hour of being called, the patient will be sent to the local A&E Department; 2 Direct monitoring of all input and urinary output The late Mr O'Connell was gentleman who remained in his room throughout his stay: He did not interact with any other residents or take meals in any of the dining rooms_ He would call for assistance when necessary. His routine was to watch TV all only leaving his room to smoke_ The information given to Monkstone House by his family detailed his daily routine, with no concerns with regard to his catheter: Accordingly, it would have been difficult to monitor his urinary input and output as his supply of fluids was supplied by his family and kept in his room, which he drank at his leisure_ Also, the information that Monkstone House received Social Services, provided by his social worker, did not provide any express instructions regarding Mr O'Connell's catheter or iluid input and output and only reference to his catheter being emptied three times In addition, there was no mention of any concern made by his family or professionals regarding past or present problems with his catheter before or during his admission to Monkstone House_ Notwithstanding this, the Monkstone House policy has been reviewed following Mr O'Connell's death. The catheter care policy has been reviewed and all staff have now been given extra training: In addition, urinary input and output monitoring charts have been put in place for all clients_ The Monkstone House and procedures which are now in place have also been reviewed and approved by CSSIW, as documented in Monkstone House's recent inspection report which took place in August 2013. this, day, from day: Policy
nun 3 Failure to undergo clinical assessment From the Friday to Sunday Mr O'Connell was monitored by staff at Monkstone House and this was recorded in Monkstone House's daily logs: Mr 0'Connell was checked hourly throughout the night and his family were kept informed of his condition. No concerns were expressed and no visits were made by the family: Senior staff followed the family's decision not to send Mr O'Connell to A&E: However; if senior staff felt at any point that Mr O'Connell's condition was deteriorating any further; then medical advice would have been sought immediately, notwithstanding the fact that Mr O'Connell's family had requested that he should not be admitted to hospital. Throughout the period from Friday to Sunday Mr O'Connell's catheter was draining: Mr O'Connell appeared to be his normal self and in a jovial mood, evidence of which is contained in his daily records_ His condition only began to deteriorate on Sunday to the extent that emergency treatment then became necessary. Mr O'Connell's daughter arrived at Monkstone House at 12.40pm to pick Mr O'Connell up to return home. She expressed concern to a senior member of staff that Mr O'Connell was not himself. The senior member of staff , accompanied Mr OConnell's daughter to his room where she agreed that his condition had deteriorated since she had seen him last at 12 noon The GP out of hours was called, however further deterioration was noted by land an ambulance was called for by her. An ambulance arrived promptly and Mr O'Connell left Monkstone House by ambulance at approximately 1.4Opm. Following these events, Monkstone House have reviewed all of their policies and procedures regarding GP out of hours, district nurses requests for visits etc. and the appropriate action in summary has been taken: Telephone calls are now recorded to confirm the substance of all conversations between families and all other professional agencies _ 2 Catheter policy and procedure has been reviewed; fluid input and output has been revised and approved by CSSIW: 3 Meetings have been held with senior staff and if there are any concerns regarding clients, staff are to seek medical advice, ensuring that all clients are seen by a professional. If, for whatever reason clients cannot be seen at Monkstone House and if out of hours GP and nurses will not attend, Morikstone House will send the client to A&E department for assessment as soon as practical: Monkstone House is no longer offering respite facilities to clients:
nn In conclusion, we are attaching a copy of the Protection of Vulnerable Adults Strategy Meeting minutes, which took place on 18th September 2013 regarding Mr O'Connell together with some other additional policy and procedure documents which are relevant to this matter. These are: and Procedure for Catheter Care Policy and Procedure for a client needing clinical assessment Pre-Admission Assessment Form Fluid Balance Chart CSSIW Inspection Report August 2013 We trust that the above information will be of assistance and if there anything further we can assist with in dealing with , please do not hesitate to contact us_
N The last phone call to was at 12.40am. During the course of this telephone conversation a senior member of staff at Monkstone House informed that neither the district nurses nor the out of hours GP was going to attend to Mr O'Connell at Monkstone House did not want to arrange for Mr O'Connell to go to A&E: linformed the member of staff that he had spoken to the GP out of hours and he was happy for Mr OConnell to remain at Monkstone House and he would ring in the morning to see what progress had been made. Staff at Monkstone continued to monitor Mr O'Connell throughout the night and there is documentation available to confimm this. No concerns were noted during this time Notwithstanding the Morikstone House policy has now been changed with regard to clinical assessment: The effect of this is that if a health professional (either district nurse or GP) will not attend Monkstone House within one hour of being called, the patient will be sent to the local A&E Department; 2 Direct monitoring of all input and urinary output The late Mr O'Connell was gentleman who remained in his room throughout his stay: He did not interact with any other residents or take meals in any of the dining rooms_ He would call for assistance when necessary. His routine was to watch TV all only leaving his room to smoke_ The information given to Monkstone House by his family detailed his daily routine, with no concerns with regard to his catheter: Accordingly, it would have been difficult to monitor his urinary input and output as his supply of fluids was supplied by his family and kept in his room, which he drank at his leisure_ Also, the information that Monkstone House received Social Services, provided by his social worker, did not provide any express instructions regarding Mr O'Connell's catheter or iluid input and output and only reference to his catheter being emptied three times In addition, there was no mention of any concern made by his family or professionals regarding past or present problems with his catheter before or during his admission to Monkstone House_ Notwithstanding this, the Monkstone House policy has been reviewed following Mr O'Connell's death. The catheter care policy has been reviewed and all staff have now been given extra training: In addition, urinary input and output monitoring charts have been put in place for all clients_ The Monkstone House and procedures which are now in place have also been reviewed and approved by CSSIW, as documented in Monkstone House's recent inspection report which took place in August 2013. this, day, from day: Policy
nun 3 Failure to undergo clinical assessment From the Friday to Sunday Mr O'Connell was monitored by staff at Monkstone House and this was recorded in Monkstone House's daily logs: Mr 0'Connell was checked hourly throughout the night and his family were kept informed of his condition. No concerns were expressed and no visits were made by the family: Senior staff followed the family's decision not to send Mr O'Connell to A&E: However; if senior staff felt at any point that Mr O'Connell's condition was deteriorating any further; then medical advice would have been sought immediately, notwithstanding the fact that Mr O'Connell's family had requested that he should not be admitted to hospital. Throughout the period from Friday to Sunday Mr O'Connell's catheter was draining: Mr O'Connell appeared to be his normal self and in a jovial mood, evidence of which is contained in his daily records_ His condition only began to deteriorate on Sunday to the extent that emergency treatment then became necessary. Mr O'Connell's daughter arrived at Monkstone House at 12.40pm to pick Mr O'Connell up to return home. She expressed concern to a senior member of staff that Mr O'Connell was not himself. The senior member of staff , accompanied Mr OConnell's daughter to his room where she agreed that his condition had deteriorated since she had seen him last at 12 noon The GP out of hours was called, however further deterioration was noted by land an ambulance was called for by her. An ambulance arrived promptly and Mr O'Connell left Monkstone House by ambulance at approximately 1.4Opm. Following these events, Monkstone House have reviewed all of their policies and procedures regarding GP out of hours, district nurses requests for visits etc. and the appropriate action in summary has been taken: Telephone calls are now recorded to confirm the substance of all conversations between families and all other professional agencies _ 2 Catheter policy and procedure has been reviewed; fluid input and output has been revised and approved by CSSIW: 3 Meetings have been held with senior staff and if there are any concerns regarding clients, staff are to seek medical advice, ensuring that all clients are seen by a professional. If, for whatever reason clients cannot be seen at Monkstone House and if out of hours GP and nurses will not attend, Morikstone House will send the client to A&E department for assessment as soon as practical: Monkstone House is no longer offering respite facilities to clients:
nn In conclusion, we are attaching a copy of the Protection of Vulnerable Adults Strategy Meeting minutes, which took place on 18th September 2013 regarding Mr O'Connell together with some other additional policy and procedure documents which are relevant to this matter. These are: and Procedure for Catheter Care Policy and Procedure for a client needing clinical assessment Pre-Admission Assessment Form Fluid Balance Chart CSSIW Inspection Report August 2013 We trust that the above information will be of assistance and if there anything further we can assist with in dealing with , please do not hesitate to contact us_