Janet Spencer
PFD Report
All Responded
Ref: 2023-0541
All 1 response received
· Deadline: 29 Nov 2023
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Response Status
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56-Day Deadline
29 Nov 2023
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
Janet had a recent but significant history of frequent falls, some causing serious injury. A care assessment commenced on 6th May 2022 and updated on 10th May 2022, identified that she had reablement potential but further assessment of her needs was required. On 16th May 2022 she was admitted to the assessment unit at Gladstone House, an assisted living facility. On 25th May she suffered a further fall, fracturing her right neck of femur. She was admitted to Kings Mill Hospital. On 22nd June 2022 a discharge to assess referral form was completed. It included limited detail of her care needs and a single-sentence reference to the fall on 25th May. On 14th July 2022, Janet was discharged to Nightingale Care and Nursing Home. On 18th July 2022 she had an unwitnessed fall there. Fortunately, she sustained no significant injuries on that occasion. On 26th August 2022 Janet transferred to Gladstone House. On 30th August 2022 she suffered the fall which ultimately led to her death.
The evidence heard from staff at both care facilities was consistent in two significant respects: i) they were provided with very little information in advance of the transfer; and ii) the transfer was arranged hastily, which resulted in both facilities having limited opportunity to liaise with each other, or to prepare for and ensure it proceeded smoothly.
I remain unclear as to the precise reasons for Janet’s transfer from Nightingale to Gladstone House on 26th August 2022 and why it appears to have been arranged with such haste. No updated care assessment was made prior to transfer.
An error occurred between the care facilities which resulted in Janet not receiving two of her prescribed medications following her transfer to Gladstone House. While this did not cause or contribute to Janet’s death, the importance of care facility residents receiving the correct medication needs no emphasis. This error occurred in part because of flaws in the systems of the two care facilities, which I am satisfied have since been addressed. However, the evidence suggests that it was also due, in part, to the haste with which the transfer was arranged and the lack of coordination of it by the social care team.
I heard evidence that the systems in respect of discharges and transfers to Gladstone House have since been improved. I was told that both that provider and the social care team based on site, do now have better systems in place and work closely together to ensure that sufficient information is provided in respect of any referral. However, I was also told that Gladstone House have no power to refuse any referral even if they consider the information provided by social care to be insufficient. Furthermore, the Adult and Social Care Team, Team Manager who gave evidence on behalf of NCC, was (through no fault of her own) unable to assist me with details of any changes that may have occurred more widely within the discharge to assess team since August 2022. I cannot therefore be satisfied that these issues have been adequately addressed.
1. The systems in place in respect of discharge to assess patients do not appear to ensure patients are discharged or transferred between care facilities with an adequate and up to date risk assessment and care plan in place.
2. The systems in place in respect of discharge to assess patients do not appear to ensure a smooth transition between care facilities, especially when transfers are arranged at pace. In particular, they do not appear to ensure that all involved have the information they require to contribute effectively to the transfer process. Although they did not cause or contribute to Janet Spencer’s death, I am concerned that the issues identified above give rise to a risk of deaths occurring if they go unaddressed.
The evidence heard from staff at both care facilities was consistent in two significant respects: i) they were provided with very little information in advance of the transfer; and ii) the transfer was arranged hastily, which resulted in both facilities having limited opportunity to liaise with each other, or to prepare for and ensure it proceeded smoothly.
I remain unclear as to the precise reasons for Janet’s transfer from Nightingale to Gladstone House on 26th August 2022 and why it appears to have been arranged with such haste. No updated care assessment was made prior to transfer.
An error occurred between the care facilities which resulted in Janet not receiving two of her prescribed medications following her transfer to Gladstone House. While this did not cause or contribute to Janet’s death, the importance of care facility residents receiving the correct medication needs no emphasis. This error occurred in part because of flaws in the systems of the two care facilities, which I am satisfied have since been addressed. However, the evidence suggests that it was also due, in part, to the haste with which the transfer was arranged and the lack of coordination of it by the social care team.
I heard evidence that the systems in respect of discharges and transfers to Gladstone House have since been improved. I was told that both that provider and the social care team based on site, do now have better systems in place and work closely together to ensure that sufficient information is provided in respect of any referral. However, I was also told that Gladstone House have no power to refuse any referral even if they consider the information provided by social care to be insufficient. Furthermore, the Adult and Social Care Team, Team Manager who gave evidence on behalf of NCC, was (through no fault of her own) unable to assist me with details of any changes that may have occurred more widely within the discharge to assess team since August 2022. I cannot therefore be satisfied that these issues have been adequately addressed.
1. The systems in place in respect of discharge to assess patients do not appear to ensure patients are discharged or transferred between care facilities with an adequate and up to date risk assessment and care plan in place.
2. The systems in place in respect of discharge to assess patients do not appear to ensure a smooth transition between care facilities, especially when transfers are arranged at pace. In particular, they do not appear to ensure that all involved have the information they require to contribute effectively to the transfer process. Although they did not cause or contribute to Janet Spencer’s death, I am concerned that the issues identified above give rise to a risk of deaths occurring if they go unaddressed.
Responses
Nottinghamshire County Council has implemented a new process and referral/assessment form for all people moving into Assessment Flat accommodation to mitigate communication breakdowns, ensuring comprehensive patient information is recorded and shared. The existing transfer arrangements process has also been reviewed and improved.
AI summary
View full response
Dear Michael 28 November 2023 This matter is being dealt with by:
W nottinghamshire.gov.uk Private and Confidential To be opened by addressee only Michael Wall HM Assistant Coroner For Nottingham City and Nottinghamshire
4. The Discharge to Assess form is sent to the ‘Transfer of Care Hub’ - which is a multi-disciplinary Team sited within the hospital. Each referral to the Hub is discussed by the team which includes NHS and LA Social Care professionals, also linking with District Council and Community & Voluntary Sector staff as required. The Multi- Disciplinary Team make a joint decision regarding which pathway the person requires to ensure a safe discharge from hospital with appropriate care, support and reablement to promote their wellbeing and independence.
5. The Pathway decision and referral forms are shared with the care provider, for example for people leaving hospital to return home on Pathway 1 (social care supported discharge) this information is shared with the LA Services, and for those being supported via Pathway 1 by Community Health Provision- information is shared accordingly. This information pack also includes a discharge summary and medication list / arrangements.
6. In Mrs Spencer’s case she was assessed to require a Pathway 1 discharge (Social Care Supported Discharge), the Multi- Disciplinary Team identified that she would benefit from further assessment and reablement in an Assessment Flat- which in her local area are situated at Gladstone Court. However, as there was not an Assessment Flat available when she was ready to leave hospital, interim care arrangements were made at a local Residential Care Home and she was discharged safely to that location, the Nightingale Care Home manager was sent the D2A Form information as part of the preliminary discharge planning and agreed that they could meet her needs, discharge went smoothly.
7. The transfer from Nightingale Care Home to the Assessment Flat was not satisfactory as highlighted in HM Coroner’s report, the Local Authority policy and guidance was not followed in terms of ensuring that arrangements were in place for Mrs Spencer’s medication, and recording of information regarding the care arrangements required This has been addressed via a Safeguarding Adults Enquiry (Sec. 42, Care Act 2014), with recommendations and action plan implemented (please see para.11).
Partnership working and Service Improvements
8. To ensure continued quality assurance and service improvements there are weekly Multi- Disciplinary Workshops as part of the Integrated Care System Discharge to Assess Planning and Service Provision. This includes a regular review of Transfer of Care Hubs and Multi- Disciplinary Team working practices. Each month there is a focussed workshop on each Pathway 1-3 and then a more strategic workshop as part of this agreed work plan for the Integrated Care System. These workshops include senior operational and strategic representatives from all key partner agencies and is key to partnership working and collaborative culture to improving hospital discharge for people and their carers/families.
9. At a more operational level, the Transfer of Care Hubs hold weekly audits and reflective discussions of hospital discharges that have gone well or where improvements are required.
10. Another key improvement for Hospital Discharge planning across the Integrated Care System been the implementation of a shared dataset which tracks people through their hospital admission and pathway out of hospital. This dataset and dashboard is used by NHS and LA partners to ensure that all people leaving hospital are supported to do so in as timely and safe a manner as possible.
Nottinghamshire County Council Service Improvements
11. The LA recognises that improvements have been required in the clear and accurate sharing of up-to-date information for admission to the Assessment Flats, as illustrated by Mrs Spencer’s situation. To ensure that the risk of any future breakdown in communication is mitigated, a new process and referral / assessment form has been implemented for all people moving into Assessment Flat accommodation. This process is for hospital and community admissions into
the service. The assessment form outlines the person’s care and support needs, any risks and updated medical information including medication. This is recorded on the Social Care Electronic Record and shared with the care provider at Gladstone Court which is Fosse Healthcare.
12. There are also weekly meetings for the Discharge to Assessment Team Managers from the Local Authority where practice is reviewed, and improvements discussed and shared across the service.
The systems in place in respect of discharge to assess patients do not appear to ensure a smooth transition between care facilities, especially when transfers are arranged at pace. In particular, they do not appear to ensure that all involved have the information they require to contribute effectively to the transfer process.
13. The LA would expect that the process described above is followed regarding hospital discharge, with information shared about a person’s care and support needs prior to any transfer to a different care provision or arrangements (whether at home or in a 24-hour care setting). This includes the care requirements, risk assessment and mental capacity / best interests’ information. As explained above, whilst the Local Authority has a clear process in place for arrangements by LA Social Care staff for people moving between care facilities, this was not robust followed in the case of the arrangements for Mrs Spencer and her move to Gladstone Court. This process has been reviewed and improved in order ensure a more robust transfer arrangements process for people requiring this service in the future.
W nottinghamshire.gov.uk Private and Confidential To be opened by addressee only Michael Wall HM Assistant Coroner For Nottingham City and Nottinghamshire
4. The Discharge to Assess form is sent to the ‘Transfer of Care Hub’ - which is a multi-disciplinary Team sited within the hospital. Each referral to the Hub is discussed by the team which includes NHS and LA Social Care professionals, also linking with District Council and Community & Voluntary Sector staff as required. The Multi- Disciplinary Team make a joint decision regarding which pathway the person requires to ensure a safe discharge from hospital with appropriate care, support and reablement to promote their wellbeing and independence.
5. The Pathway decision and referral forms are shared with the care provider, for example for people leaving hospital to return home on Pathway 1 (social care supported discharge) this information is shared with the LA Services, and for those being supported via Pathway 1 by Community Health Provision- information is shared accordingly. This information pack also includes a discharge summary and medication list / arrangements.
6. In Mrs Spencer’s case she was assessed to require a Pathway 1 discharge (Social Care Supported Discharge), the Multi- Disciplinary Team identified that she would benefit from further assessment and reablement in an Assessment Flat- which in her local area are situated at Gladstone Court. However, as there was not an Assessment Flat available when she was ready to leave hospital, interim care arrangements were made at a local Residential Care Home and she was discharged safely to that location, the Nightingale Care Home manager was sent the D2A Form information as part of the preliminary discharge planning and agreed that they could meet her needs, discharge went smoothly.
7. The transfer from Nightingale Care Home to the Assessment Flat was not satisfactory as highlighted in HM Coroner’s report, the Local Authority policy and guidance was not followed in terms of ensuring that arrangements were in place for Mrs Spencer’s medication, and recording of information regarding the care arrangements required This has been addressed via a Safeguarding Adults Enquiry (Sec. 42, Care Act 2014), with recommendations and action plan implemented (please see para.11).
Partnership working and Service Improvements
8. To ensure continued quality assurance and service improvements there are weekly Multi- Disciplinary Workshops as part of the Integrated Care System Discharge to Assess Planning and Service Provision. This includes a regular review of Transfer of Care Hubs and Multi- Disciplinary Team working practices. Each month there is a focussed workshop on each Pathway 1-3 and then a more strategic workshop as part of this agreed work plan for the Integrated Care System. These workshops include senior operational and strategic representatives from all key partner agencies and is key to partnership working and collaborative culture to improving hospital discharge for people and their carers/families.
9. At a more operational level, the Transfer of Care Hubs hold weekly audits and reflective discussions of hospital discharges that have gone well or where improvements are required.
10. Another key improvement for Hospital Discharge planning across the Integrated Care System been the implementation of a shared dataset which tracks people through their hospital admission and pathway out of hospital. This dataset and dashboard is used by NHS and LA partners to ensure that all people leaving hospital are supported to do so in as timely and safe a manner as possible.
Nottinghamshire County Council Service Improvements
11. The LA recognises that improvements have been required in the clear and accurate sharing of up-to-date information for admission to the Assessment Flats, as illustrated by Mrs Spencer’s situation. To ensure that the risk of any future breakdown in communication is mitigated, a new process and referral / assessment form has been implemented for all people moving into Assessment Flat accommodation. This process is for hospital and community admissions into
the service. The assessment form outlines the person’s care and support needs, any risks and updated medical information including medication. This is recorded on the Social Care Electronic Record and shared with the care provider at Gladstone Court which is Fosse Healthcare.
12. There are also weekly meetings for the Discharge to Assessment Team Managers from the Local Authority where practice is reviewed, and improvements discussed and shared across the service.
The systems in place in respect of discharge to assess patients do not appear to ensure a smooth transition between care facilities, especially when transfers are arranged at pace. In particular, they do not appear to ensure that all involved have the information they require to contribute effectively to the transfer process.
13. The LA would expect that the process described above is followed regarding hospital discharge, with information shared about a person’s care and support needs prior to any transfer to a different care provision or arrangements (whether at home or in a 24-hour care setting). This includes the care requirements, risk assessment and mental capacity / best interests’ information. As explained above, whilst the Local Authority has a clear process in place for arrangements by LA Social Care staff for people moving between care facilities, this was not robust followed in the case of the arrangements for Mrs Spencer and her move to Gladstone Court. This process has been reviewed and improved in order ensure a more robust transfer arrangements process for people requiring this service in the future.
Report Sections
Investigation and Inquest
On 10 October 2022 I commenced an investigation into the death of Janet Irene SPENCER aged 76. The investigation concluded at the end of the inquest on 21 September 2023. The conclusion of the inquest was: Accident.
Copies Sent To
2. Fosse Healthcare
3. Jasmine Healthcare
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.