Terence Manning
PFD Report
Partially Responded
Ref: 2024-0495
629 days overdue · 1 response outstanding
Sent To
Response Status
Responses
1 of 2
56-Day Deadline
5 Jul 2024
629 days past deadline — 1 response outstanding
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 Terrence John Manning was a resident at Haddon Court from 29 June 2023. It was known to Haddon Court Rest Home, that Mr Manning had a propensity to eat quickly and to take food from other plates.
Mr Manning was not being fed a pureed or soft texture diet, and entries to this effect in the care records are errors in the record keeping. These errors had been caused by carers carrying forward the details of records relating to other residents from entries made on the records of those other residents.
It was noted in the evidence, that erroneous record keeping had taken place over a period of time and involved multiple carers. It was caused by carers transposing the records of one resident into the care records of another, leading to inaccuracies.
I found that these matters gave rise to a risk of further death as the record keeping was inaccurate and did not reflect the foods being given to Mr Manning, and engaged my duty under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
Mr Manning was not being fed a pureed or soft texture diet, and entries to this effect in the care records are errors in the record keeping. These errors had been caused by carers carrying forward the details of records relating to other residents from entries made on the records of those other residents.
It was noted in the evidence, that erroneous record keeping had taken place over a period of time and involved multiple carers. It was caused by carers transposing the records of one resident into the care records of another, leading to inaccuracies.
I found that these matters gave rise to a risk of further death as the record keeping was inaccurate and did not reflect the foods being given to Mr Manning, and engaged my duty under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
Responses
Haddon Court Rest Home has reminded all staff about the importance of accurate record-keeping, particularly regarding the 'repeat functionality' in their software. They have also contacted their software provider, who committed to reviewing and potentially removing certain care categories from this function to reduce errors.
AI summary
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Dear Sir, Thank you for your report made under RegulaƟon 28 dated 10 May. In the report, you outline concerns that inaccurate entries appeared in Mr Manning’s records as to the diet with which he was provided. You record concerns that such entries were errors in record keeping caused by carers “carrying forward” or transposing the records of one resident into the care records of another. At the inquest hearing, we recall that the very capability of the soŌware concerned to allow such transposing appeared to cause you concern. In terms of our staff, we would like to reassure you that all staff have been reminded about the importance of accuracy in record keeping. We have parƟcularly reminded the staff about the risks of using what is termed the “repeat funcƟonality” of the soŌware in quesƟon, and to ensure that records are checked for accuracy aŌer use of this feature. In addiƟon, immediately following receipt of your report, we made contact with the soŌware provider, Person Centred SoŌware Ltd. We explained the background, including our receipt of your report, and the specifics of the recording system findings about the ability to transpose entries between service users. We received the following reply from their Chief Product Officer (a copy of the original emails can be supplied if necessary):
“The purpose of our care delivery solution is to give carers more time to provide care and less time spent recording care actions – we have seen huge benefit from this approach. It means that care providers have more data and better data and can make better decision. At the same time, we strive to support a proper recording with small number of mistakes done by the personnel. The “repeat functionality” is designed to make repetitive tasks and care actions quicker and easier to record. That's very beneficial if multiple residents are taking part in one activity - e.g. physical exercise. A carer may have supported multiple residents with the same care, and thus benefit from being able to repeat the same action for one resident to another; there remains however the responsibility of the user to ensure that the care record reflects the care provided. It should also be noted that the care is record ‘post the care interaction’ and would not therefore have been used to determine how a resident will have their food prepared. It is important that carers are encouraged to record the most accurate and person-centred records as possible. Based on your input, we will review the repeat functionality in detail and consider certain categories of care to be removed from the repeat functionality. That would force users to individually report the details for each resident in those selected categories. I hope this helps with the response to the coroner and addresses any concerns they have. We believe that Haddon Court Rest Home (Haddon Court Ltd) has taken robust measures to ensure records at the home meet the standards rightly expected from legal, professional and regulatory perspecƟves. We have also responded as fully as we are able to in relaƟon to bringing this maƩer to the aƩenƟon of and influencing the soŌware provider. I understand that they are currently working on the funcƟonality that will help to reduce the risk of erroneous recording. Should you require any further informaƟon or have any further concerns, please let me know.
“The purpose of our care delivery solution is to give carers more time to provide care and less time spent recording care actions – we have seen huge benefit from this approach. It means that care providers have more data and better data and can make better decision. At the same time, we strive to support a proper recording with small number of mistakes done by the personnel. The “repeat functionality” is designed to make repetitive tasks and care actions quicker and easier to record. That's very beneficial if multiple residents are taking part in one activity - e.g. physical exercise. A carer may have supported multiple residents with the same care, and thus benefit from being able to repeat the same action for one resident to another; there remains however the responsibility of the user to ensure that the care record reflects the care provided. It should also be noted that the care is record ‘post the care interaction’ and would not therefore have been used to determine how a resident will have their food prepared. It is important that carers are encouraged to record the most accurate and person-centred records as possible. Based on your input, we will review the repeat functionality in detail and consider certain categories of care to be removed from the repeat functionality. That would force users to individually report the details for each resident in those selected categories. I hope this helps with the response to the coroner and addresses any concerns they have. We believe that Haddon Court Rest Home (Haddon Court Ltd) has taken robust measures to ensure records at the home meet the standards rightly expected from legal, professional and regulatory perspecƟves. We have also responded as fully as we are able to in relaƟon to bringing this maƩer to the aƩenƟon of and influencing the soŌware provider. I understand that they are currently working on the funcƟonality that will help to reduce the risk of erroneous recording. Should you require any further informaƟon or have any further concerns, please let me know.
Report Sections
Investigation and Inquest
On 9 and 10 May 2024, at an inquest held at Blackpool Town Hall, I returned a short form conclusion that Mr Terence Manning died as a result of an accident.
I found the cause of death to be:
1(a) Hypoxic brain injury 1(b) Out of hospital cardiac arrest 1(c) Choking on a food bolus II Frontotemporal dementia
I found the cause of death to be:
1(a) Hypoxic brain injury 1(b) Out of hospital cardiac arrest 1(c) Choking on a food bolus II Frontotemporal dementia
Circumstances of the Death
I returned the following in box 3 of the Record of Inquest recorded:
Mr Terence John Manning resided at Haddon Court Rest Home, 8-14 Haddon Road, Blackpool. Mr Manning had become a resident at Haddon Court on 29 June 2023. On 22 October 2023, Mr Manning was eating a meal at the rest home, when he experienced a choking incident. Mr Manning was taken by ambulance to Blackpool Victoria Hospital where, despite receiving treatment he died on 24 October 2023. Mr Manning had been identified to have a propensity to eat quickly, but a Speech and Language Therapy (‘SALT’) referral had not been made in his case, in circumstances where there was an opportunity for such a referral to have been made. It is not possible to say as to what the conclusion of any SALT referral would have been.
Mr Terence John Manning resided at Haddon Court Rest Home, 8-14 Haddon Road, Blackpool. Mr Manning had become a resident at Haddon Court on 29 June 2023. On 22 October 2023, Mr Manning was eating a meal at the rest home, when he experienced a choking incident. Mr Manning was taken by ambulance to Blackpool Victoria Hospital where, despite receiving treatment he died on 24 October 2023. Mr Manning had been identified to have a propensity to eat quickly, but a Speech and Language Therapy (‘SALT’) referral had not been made in his case, in circumstances where there was an opportunity for such a referral to have been made. It is not possible to say as to what the conclusion of any SALT referral would have been.
Copies Sent To
Care Quality Commission
Lancashire County Council
Blackpool Council
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.