UK Inquiry Tracker

Pamela Thurston

PFD Report Partially Responded Ref: 2016-0122

Date of Report 29 March 2016

Coroner Johanna Thompson

Coroner Area Norfolk

Response Deadline ✓ from report 31 May 2016

Care Home Health related deaths

Judiciary.uk Report PDF

1 of 2 responded · Over 2 years old

Sent To

Response Status

Responses 1 of 2

56-Day Deadline 31 May 2016

Over 2 years old — no identified published response

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

Mrs Pamela Thurston was a resident at Cedar Care Home in Yelverton: She suffered from Alzheimers' dementia and required prompting in order to eat meals and also supervision in doing so_ Approximately two weeks prior to her death; Mrs Thurston was found to have stored prune stones in her mouth and had to be encouraged to spit them out: This was reported to the Care Home Manager and thereafter she was given prunes wilh stones removed, Her care plan was not altered, but a note was made for the chef to this effect, The Care Home procedure for checking that residents had been fed at mealtimes was that the chef would tick off the residents on a list kept in the kitchen. The residents were given their evening meal at approximately Spm, and breakfasts were served from approximately 8am onwards following the staff handover at that time from night to shift On the morning of 5 July 2015, Mrs Thurston had awoken early as was her tendency, and was in the care home conservatory_At approximately 11am, one of the staff day sitting became aware (hat she had not been given any breakfast and a decision was made to give her some toast: This was given to Mrs Thurston who proceeded t0 eat the toast so quickly that it became stuck in her airway which caused her to choke_ Attempts were made t0 remove the toast when the attention of the staff was drawn to lhis by another resident The nurse on duty was in a position to observe Mrs Thurston, but did not directly supervise her in the toast, The nurse was unable t0 remove the toast from Mrs Thurston's airway. Her subsequent attempts at CPR were unsuccessful, and heart rhythm was not restored until the arrival of paramedics Mrs Thurston developed bronchopneumonia as a consequence of the choking incident, and subsequently died on 7 2015 in hospital: It appears that Mrs Thurston ate the toast she had been given too quickly as consequence of hungry, having had no food since the previous evening approximately between Spm and 6pm, being a period of around 17 hours When given the toast, she was left to eat this without direct supervision. She choked on the toast, and died in hospital two days later.

Responses

DownloadThurston Response

8 Apr 2016

Response received

View full response

Dear Ms Thompson Re: Regulation 28; Response to Report to Prevent Future Deaths We refer to vour Report to Prevent Future Deaths dated 2gwh March 2016 followlng the inquest into the death of Mrs Pamela Thurston Please accept thls letter as our response to your Report ("Response' which notes the action Caring Homes Healthcare Group Limited ("Group' has taken, and intends to take, In respect of the concerns you raised in vour Report On 8th April 2016 Frank Cummins, Clinical Director, sent Memorandum to the Home Managers of all the Care Homes In the Group, with copies to the Group's Regional Managers and Head of Operatlons. The Memorandum relates to ensuring meals are given in timely manner and your concerns were explained_ The Memorandum notes that whilst service users are to be given as much cholce as possible in relation to when their meals are to be served, caution should be taken ifa service user has not eaten for a significant period of time due to them missing core meals or snacks which may make them more prone to eating quickll which could put them atan increased risk ofchoking: It is noted that any risk Is Increased where a resident has a significant cognitive or swallowing deficit: Staff have been asked to: particular attention to completing appropriate choking risk assessments for service users and ensure that all staff, including kitchen staff, are fully aware of any service users who may have a compromised swallowing reflex Ensure any service user who may be showing the symptoms ofa compromised swallowing reflex are referred to SALT in a timely manner and that the actions SALT prescribe are implemented and that all staff are aware of the recommendations (should staff experience any difficulty in gaining timely advice from the local SALT teams; Mr Cummins should be contacted who will correspond with the SALT Team to try and expedite the matter) Flspitolty (ssurtr Carlng Homes Group Tel: 01206 224 100 Crinx Ilrrtsipaliae C&p leed Bradhury House , 830 Ihe Crescent Fax: 01206 224 198 RpstTE4 Tyl ad7io, 05J67547 n7i_ Itescitt UmEG, Pntlbsry Htuze BJ0 I: Creserl 450 9001 Colchasler Business Park, Colchesler; Essox C04 9YQ vanvcaringliomes org Coxiaslc' Huane5 (rlt"3l+ 6st(04 9rq Lomucicina along Pay M

3 Ensure that snacks are available for service users between core meals and that such snacks are encouraged where a period ofover eight hours has passed since a service user last ate Ensure an appropriate risk assessment is undertaken and a referral made to SALT where service user has been known to hoard foodstuffs in their mouth 5, Ensure a tick list is in the kitchen area which documents the time a service user is served a core meal in the Home_ Where it is noticed that a significant period of time has passed between meals for a service user (eight hours or over), or where a service user has missed meal, direct observations of the service user should be maintained whilst the service user is eating their mealor snack The person in charge must designate a member of staff to undertake the observation and this should be documented in the service users notes
6. Where a service user has compromised nutritional intake, a record of foods served, the time and the amount taken should be maintained as is usual procedure. The Home Managers have been asked to discuss the Memorandum with their staff team via team meetings or other appropriate method, such as a shift handover, The Group's Regional Managers have line management responsibility for a number of Homes within the Group: The Regional Managers have been asked to discuss the matters with the Home Managers on their next monthly visit and will also sample staff knowledge. As part of our clinical governance the Regional Managers undertake a monthly visit to each Home are responsible for and complete a Senior Manager Monthly Report (SMMR} The SMMR covers a range of matters in order to determine If the Home is complylng with the required standards and the Group's policies and procedures; The SMMR was amended on 18th Aprll 2016 following discussion at the Group'$ Clinical Risk Committee to include requirement for Regional Managers to monitor Homes adherence to the Memorandum moving forward, The first SMMR to include the amended area will be undertaken during
2016. The Group' s Heads of Operations line-manage the Regional Managers and revlew the monthly audits to ensure that the Regional Managers are undertaking the required checks The knowledge and implementation of the Memorandum will be monitored throughout the management structure of the Group, as noted above, and should any further action be necessary then the Group will into place the required steps;" Thank You for your Report ad we trust that the above addresses your concerns adequately.

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action,

Report Sections

Investigation and Inquest

On 13 July 2015 commenced an investigation into the death of PAMELA JOYCE THURSTON aged 78_ The investigation concluded at the end of the inquest on 29 February 2016. The conclusion of the inquest was accidental death due to Ia) Bronchopneumonia; 2 Alzheimers Disease.

Circumstances of the Death

Mrs Thurston died at Norfolk and Norwich University Hospital on 7 July 2015 after choking on some toast she was given at Cedar Care Home in Yelverton, Norfolk two days earlier: