Peter Furness
PFD Report
All Responded
Ref: 2015-0398
All 1 response received
· Deadline: 30 Nov 2015
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
30 Nov 2015
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
_ _ The Registered Individual responsible for the care home and the current Manager both acknowledged that within current systems and protocols operating at the home, there is no documented process by which incidents or concerns are escalated s0 as to result in a multi disciplinary team meeting aimed at reviewing the risk assessments and care plan relating to the vulnerable person within their care. doing and
Responses
Response received
View full response
Dear Mr John Gittins, In order to fully comply with the regulation 28 we have addressed our alert system_ This will alert all staff to changes in our residents' physical conditions and their behaviours. The new system is self- explanatory (please see copy's sent initially a simple alert form is completed by whoever first identifies the concern; this is then evaluated by the qualified nurse in and is escalated by the nurse (please see copies sent): This process gives clear instruction throughout the alert process and will inevitably reduce risk and involve the wider disciplinary team immediately if necessary. This remains a work in progress and it will be evaluated and amended to what is working and what is not: All staff have undergone a training session and undergone a supervision on the changes. The new system of raising an alert is supported by posters placed around the building for family's and visitors to be aware of how we deal with concerns and alerts. (Incidents and accidents are also covered within the alert process and form part of the new policy): have together policy and alert/incident processes and have included flow charts for all staff, alert and incident forms, new handover sheets with 7 follow up and a new alert poster All staff have signed to say they have read and understood the policy and alert procedure: Two red alerts files have been developed for both sides of the home so that staff can easily report and follow up on all concerns. Please contact me if you require any further information:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action.
Report Sections
Investigation and Inquest
On 16th of October 2014 commenced an investigation into the death of Peter Scott Furness then aged sixty six. The investigation concluded at the end of the inquest on the 30h of September 2015. The conclusion of the inquest was Accidental Death; the medical cause of death being 1(a) Choking on a Latex Glove (b) Dementia_
Circumstances of the Death
The Deceased, who had been diagnosed with Frontal Lobe Dementia, was a resident at the Nursing Home which provides care for persons with dementia He was known to be at risk of placing non-edible items in his mouth and had been observed so on a number of occasions_ Although risk assessments had been undertaken he collapsed on the 13th of October 2014 and was verified dead at the home at 12.32 hours A Post Mortem established that he had choked on a latex glove two further gloves were found in his stomach which had been ingested previously.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.