Victor Costello
PFD Report
All Responded
Ref: 2024-0141
All 1 response received
· Deadline: 9 May 2024
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
9 May 2024
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
Mr Costello was nil by mouth and PEG fed. His family raised concerns that Mr Costello had told them he had been drinking water from the taps in his bathroom. Evidence was given at the inquest by the Nursing Home Manager that such concerns were communicated to all staff. However, further evidence given at the inquest showed that such communication was not effective (the nurse in charge and the two care assistants who were on duty on the morning Mr Costello was taken to hospital, all denied being aware of such concerns).
Responses
Response received
View full response
Primrose Court Nursing Home South Road Norton Stockton-on-Tees TS20 2TB Tel: 01642530750
Date: 26/03/2024 Respected sir/ Madam, Jo Wharton HM Assistant Coroner for Teesside & Hartlepool The Coroner’s Office Middlesbrough Town Hall Albert Road Middleborough TS1 2QJ
I confirm receipt of your report to prevent future deaths report dated 14 March 2024, following the inquest into the death of Victor Costello.
As an organisation we have taken your comments and following actions are being proposed to prevent future deaths:
Actions Responsible people Time Scale We have communicated to all staff the coroner’s concern and the importance of effective communication including use of the electronic documentation system (see item below), daily handover sheets and verbal communication between shifts. Chief Executive-
Operation Director-
Home Manger-
All nursing and senior staff We had an all staff meeting on 22nd March
2024. We will schedule further meetings for those staff who did not attend. We are implementing an upgraded cloud based electronic documentation system where staff can easily look at each residents’ risks, alerts, and special instructions. Chief Executive-
Operation Director-
Home Manger-
All nursing and senior staff The full implementation of the new electronic documentation system will be on 1st June
2024.
We have made sure that effective and robust handovers take place between day and night staff to include explaining risks associated with Home Manger-
All nursing and senior staff, Ongoing.
residents to include any complaints and concerns raised by family, external agencies and staff. to oversee the effectiveness. The Home Manager & Operations Director will keep their record of ha and any shortfalls will be addressed. The management will monitor handovers as part of our regular audits. We are also making sure that for all residents who are on modified diet and fluids, their risk assessments and care plans are detailed and will be shared with next of kin to make sure all the information is correct.
- Operations Director, will keep their record of our checks and any shortfalls will be addressed.
On going Taking into consideration of Coroner’s comments, we have written to all service users and families about our actions.
- Chief executive. 08/04/2024
Thank you for bringing this issue to our attention.
Date: 26/03/2024 Respected sir/ Madam, Jo Wharton HM Assistant Coroner for Teesside & Hartlepool The Coroner’s Office Middlesbrough Town Hall Albert Road Middleborough TS1 2QJ
I confirm receipt of your report to prevent future deaths report dated 14 March 2024, following the inquest into the death of Victor Costello.
As an organisation we have taken your comments and following actions are being proposed to prevent future deaths:
Actions Responsible people Time Scale We have communicated to all staff the coroner’s concern and the importance of effective communication including use of the electronic documentation system (see item below), daily handover sheets and verbal communication between shifts. Chief Executive-
Operation Director-
Home Manger-
All nursing and senior staff We had an all staff meeting on 22nd March
2024. We will schedule further meetings for those staff who did not attend. We are implementing an upgraded cloud based electronic documentation system where staff can easily look at each residents’ risks, alerts, and special instructions. Chief Executive-
Operation Director-
Home Manger-
All nursing and senior staff The full implementation of the new electronic documentation system will be on 1st June
2024.
We have made sure that effective and robust handovers take place between day and night staff to include explaining risks associated with Home Manger-
All nursing and senior staff, Ongoing.
residents to include any complaints and concerns raised by family, external agencies and staff. to oversee the effectiveness. The Home Manager & Operations Director will keep their record of ha and any shortfalls will be addressed. The management will monitor handovers as part of our regular audits. We are also making sure that for all residents who are on modified diet and fluids, their risk assessments and care plans are detailed and will be shared with next of kin to make sure all the information is correct.
- Operations Director, will keep their record of our checks and any shortfalls will be addressed.
On going Taking into consideration of Coroner’s comments, we have written to all service users and families about our actions.
- Chief executive. 08/04/2024
Thank you for bringing this issue to our attention.
Report Sections
Investigation and Inquest
On 13 March 2024, I opened an investigation into the death of Victor Valentine COSTELLO, aged 84. The investigation concluded at the end of the inquest also held on 13 March 2024. I made a determination that death was from natural causes. The medical cause of death was:-
• 1(a) bronchopneumonia
• 2 cerebral infarction and generalised atherosclerosis
• 1(a) bronchopneumonia
• 2 cerebral infarction and generalised atherosclerosis
Circumstances of the Death
Mr Costello was a resident at Primrose Court Nursing Home. He was taken to hospital on the morning of the 17th February 2020 and passed away there six days later from naturally occurring disease.
Copies Sent To
Care Quality Commission
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.