John Edwards
PFD Report
Partially Responded
Ref: 2018-0015
1 of 2 responded · Over 2 years old
Response Status
Responses
1 of 2
56-Day Deadline
8 Mar 2018
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
_ No Staffordshire Place; Sta fford, STI6 2LP Tel 01785 276127 Fax 01785 276128 Joy the help His
(1) Southwinds Care home did not appear to be able to cope with Mr Edwards complex care needs. Consequently the original placement appeared to be inappropriate (2) The Home had an inadequate policy to deal with falls and no policy for pressure sore prevention and care (3) Care Home staff applied a seizure policy which was not specific to the resident (4) Care Home staff failed to seek medical assistance following seizures.
(5) Care Home staff failed to deal with significant bruising which developed 8 days after admission to the Care Home (6) Care records were retrospectively filled in_ Staff and management failed to recognise and seek help for the residents deteriorating condition other than by way of an out of hours attendance when the GP was given minimal information and the urgent follow Up request was not done: (8) Staff were unaware that medication brought in by the family was available to Mr Edwards, therefore it was not given. None was sought from the GP_ (9) Non patient specific dressings were used on pressure sores.
(10) A non-patient specific mattress was used on his bed (11) Visits by the placement officer and disability nurse failed to identify Mr Edward's deteriorating condition:
(1) Southwinds Care home did not appear to be able to cope with Mr Edwards complex care needs. Consequently the original placement appeared to be inappropriate (2) The Home had an inadequate policy to deal with falls and no policy for pressure sore prevention and care (3) Care Home staff applied a seizure policy which was not specific to the resident (4) Care Home staff failed to seek medical assistance following seizures.
(5) Care Home staff failed to deal with significant bruising which developed 8 days after admission to the Care Home (6) Care records were retrospectively filled in_ Staff and management failed to recognise and seek help for the residents deteriorating condition other than by way of an out of hours attendance when the GP was given minimal information and the urgent follow Up request was not done: (8) Staff were unaware that medication brought in by the family was available to Mr Edwards, therefore it was not given. None was sought from the GP_ (9) Non patient specific dressings were used on pressure sores.
(10) A non-patient specific mattress was used on his bed (11) Visits by the placement officer and disability nurse failed to identify Mr Edward's deteriorating condition:
Responses
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3. There was no seizure policy supplied upon admission. Southwinds general policy as to epilepsy was followed. Upon admission there was no indication that Mr Edwards had had seizures. If there is a history of seizures then it was usual for a specific policy for that resident to accompany upon admission, which would then be followed. Mr Edwards was not prescribed any epilepsy medication to the knowledge of Southwinds; Seizures were micronic and recorded and general procedure followed.
5. The bruising was documented. No skin was broken, and Mr Edwards was observed.
6. The only record that was not completed contemporaneously was an entry that the Doctor called as to the chest infection of Mr Edwards. This was made the following afternoon upon the staff member concerned coming on shift. Medical advice for Mr Edwards was sought at the appropriate time. The Doctor was provided with full information and all questions raised by him were ansivered. There is no recollection as to the out of hours Doctor suggesting any urgent referral and no documentation (other than prescription which was obtained straight away) was left by the Doctor All medication brought in by the family of Mr Edwards was entered in the MAR sheets and subsequently given to Mr Edwards as appropriate, and only by staff trained to administer medication_ There was never any suggestion that the dressing applied for the comfort of Mr Edwards was in any way incorrect:
10. There was never any suggestion that the mattress provided for Mr Edwards was in any way incorrect or improperly used:
11. Section 6. As the proprietor of Southwinds decided, after over 30 years of providing care, to retire, and accordingly, Southwinds closed in December
2017. In this circumstance there is no action that Southwinds can take:
3. There was no seizure policy supplied upon admission. Southwinds general policy as to epilepsy was followed. Upon admission there was no indication that Mr Edwards had had seizures. If there is a history of seizures then it was usual for a specific policy for that resident to accompany upon admission, which would then be followed. Mr Edwards was not prescribed any epilepsy medication to the knowledge of Southwinds; Seizures were micronic and recorded and general procedure followed.
5. The bruising was documented. No skin was broken, and Mr Edwards was observed.
6. The only record that was not completed contemporaneously was an entry that the Doctor called as to the chest infection of Mr Edwards. This was made the following afternoon upon the staff member concerned coming on shift. Medical advice for Mr Edwards was sought at the appropriate time. The Doctor was provided with full information and all questions raised by him were ansivered. There is no recollection as to the out of hours Doctor suggesting any urgent referral and no documentation (other than prescription which was obtained straight away) was left by the Doctor All medication brought in by the family of Mr Edwards was entered in the MAR sheets and subsequently given to Mr Edwards as appropriate, and only by staff trained to administer medication_ There was never any suggestion that the dressing applied for the comfort of Mr Edwards was in any way incorrect:
10. There was never any suggestion that the mattress provided for Mr Edwards was in any way incorrect or improperly used:
11. Section 6. As the proprietor of Southwinds decided, after over 30 years of providing care, to retire, and accordingly, Southwinds closed in December
2017. In this circumstance there is no action that Southwinds can take:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action.
Report Sections
Investigation and Inquest
On 06/01/2017 | commenced an investigation into the death of John Keith Edwards, 64. The investigation concluded at the end of the inquest on 10.1.2018. The conclusion of the inquest was: Accidental death contributed to by neglect
Circumstances of the Death
The deceased was 64 years of age and had a medical history which included down's syndrome, heart pacemaker, dementia, Osteoporosis and celiac disease. He was admitted to Southwinds Care Home Burntwood for respite on 1st October 2016. His falls risk assessment was poor: He suffered 2 slip falls on the 2nd and 3r October 2016 and 2 seizures on the 3rd October 2016. No medical was sought and thereafter he was largely wheel chair bound: Significant bruising was noted on the 8" October 2016. Subsequent docurnentation was retrospective and poor: An out of hours GP was called on the 13th October 2016. symptoms were poorly relayed to the GP and he was told only about a suspected chest infection: He prescribed prophylactic antibiotics and advised urgent referral to his own GP. This was not done: There was no evidence of a skin care plan. District nurses were called in on the 24th October 2016 to attend to a significant pressure sore. He was found to be screaming in pain and with obvious deformity of lower limbs. He was admitted to Good Hope Hospital and diagnosed with an old left acetabular fracture, an old displaced right neck of femur fracture, bilateral pulmonary embolus, possible liver laceration, pneumonia, congestive cardiac failure sacral and left thigh ulceration: The original fractures had occurred well before his admission to the home. However his subsequent rapid decline was due to a combination of the subsequent falls, seizures, reduced mobility and development of pressure sores in the home: He was discharged from the hospital to Hoar Cross Nursing Home Abbotts Bromley where he died at 22.41 hours on the 19th December 2016.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.