Raymond Powell
PFD Report
All Responded
Ref: 2021-0089
All 1 response received
· Deadline: 24 May 2021
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
24 May 2021
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
1. The nursing home manager confirmed that Cole Valley Nursing Home had not conducted an internal investigation into the circumstances of Raymond's death. The rational was "no foul play or inappropriate behaviour was suspected. Staff acted appropriately and phoned 999". I am concerned that it was not thought necessary to formally review the appropriateness of Raymond's falls risk assessment and the nursing home's policies and procedures to see what lessons could be learned to improve the safety of other residents.
2. The inquest did in fact reveal concerns around the nursing home's policies and procedures.
(1) The nursing home manager confirmed that a preceding fall (most likely on 15 October) had not been recorded anywhere within Raymond's file and this was the first time she was aware of a preceding fall (Raymond's family's evidence was they were told during a visit on 15 October, and nursing home carer confirmed there was a preceding fall a few weeks earlier). The nursing home manager was unable to explain why this preceding fall had not been recorded anywhere.
(2) The nursing home manager in her written report to the Coroner stated that Raymond's falls risk assessment had been updated. However, the evidence revealed in fact the falls risk assessment had been created on 30 September upon Raymond's arrival, and had never been updated. Raymond's named nurse should have reviewed and updated it at the end of October with the preceding fall on 15 October being a key factor in the updated assessment. The nursing home manager was unable to explain why the named nurse did not update the falls risk assessment as expected.
(3) On 3 November staff were observing Raymond every 15 minutes however they only endorsed the 30 minute boxes on his observation log meaning it was misleading.
3. The nursing home failed to comply with repeated court orders to supply relevant evidence. On 14 December the nursing home manager was ordered to supply evidence by 18 January. With no response the court order was extended on 8 February to 10 February. One day late, on 11 February, the nursing home manager supplied the witness statements but no documents. On 16 February the nursing home manager was ordered to supply the documents by 23 February. With no response the nursing home manager was served with a schedule 5 notice containing a penal notice to supply the documents by 18 March. In breach of the schedule 5 notice, on 22 March the nursing home manager supplied some but not all documents. I did not accept the reported problem with an email account as justifying the repeated failure to comply with court orders for 3 months. In summary, I am concerned that the nursing home has not sought to learn the lessons from the circumstances of Raymond's death and as a consequence there is an ongoing risk to other residents.
2. The inquest did in fact reveal concerns around the nursing home's policies and procedures.
(1) The nursing home manager confirmed that a preceding fall (most likely on 15 October) had not been recorded anywhere within Raymond's file and this was the first time she was aware of a preceding fall (Raymond's family's evidence was they were told during a visit on 15 October, and nursing home carer confirmed there was a preceding fall a few weeks earlier). The nursing home manager was unable to explain why this preceding fall had not been recorded anywhere.
(2) The nursing home manager in her written report to the Coroner stated that Raymond's falls risk assessment had been updated. However, the evidence revealed in fact the falls risk assessment had been created on 30 September upon Raymond's arrival, and had never been updated. Raymond's named nurse should have reviewed and updated it at the end of October with the preceding fall on 15 October being a key factor in the updated assessment. The nursing home manager was unable to explain why the named nurse did not update the falls risk assessment as expected.
(3) On 3 November staff were observing Raymond every 15 minutes however they only endorsed the 30 minute boxes on his observation log meaning it was misleading.
3. The nursing home failed to comply with repeated court orders to supply relevant evidence. On 14 December the nursing home manager was ordered to supply evidence by 18 January. With no response the court order was extended on 8 February to 10 February. One day late, on 11 February, the nursing home manager supplied the witness statements but no documents. On 16 February the nursing home manager was ordered to supply the documents by 23 February. With no response the nursing home manager was served with a schedule 5 notice containing a penal notice to supply the documents by 18 March. In breach of the schedule 5 notice, on 22 March the nursing home manager supplied some but not all documents. I did not accept the reported problem with an email account as justifying the repeated failure to comply with court orders for 3 months. In summary, I am concerned that the nursing home has not sought to learn the lessons from the circumstances of Raymond's death and as a consequence there is an ongoing risk to other residents.
Responses
Cole Valley Nursing Home has implemented several new measures, including a requirement for the manager to conduct internal investigations for all falls, a robust new post-falls protocol folder, and a new daily manager's report/handover. They have also promoted an RGN to Deputy Manager and implemented a daily task folder for nurses.
AI summary
View full response
Cole Valley Nursing Home 326 Haunch Lane, Kings Heath, Birmingham, B13 0PN
Prevention of Future Deaths Notice Response 24th May 2021
To whom it may concern
1. Manager to conduct internal investigations to all falls and attach action plans. All falls and incidents to be reported on the weekly manager’s report and submitted to Nominated Individual.
2. The Manager has reviewed current documentation regarding post falls reporting and observing. The manager agrees that post documentation protocols was not substantial and did not accurately reflect the observations that took place on the day, so has implemented a new robust post falls protocol folder for the nursing team. This is allocated in one place and therefore nurses can easily access documents. This protocol now gives guidance and clear directions to follow. This protocol also has a NEWS chart that is included within this pack and a timed observation log post fall. Regarding the previous fall, the manager has reviewed archived documentation but is unable to locate any documentation to support the reported proceeding fall on or around the 15th October
2021. The manager has spoken to about this concern. said he was extremely nervous about this situation and had many anxiety attacks before attending Coroner’s Court. stated he that he panicked throughout the questioning and was not completely sure about the fall around this time. The manager has however, implemented a new manager’s report/handover for nurses to complete daily and every night. The manager to review handover daily. A Daily Walkabout Form is also in place. This identifies if there has been any accidents or incidents in the last 24 hours and what actions have been done, such as evaluating care needs of the individual involved. Cole Valley Nursing Home has promoted an RGN to Deputy Manager with supernumerary time to assist the manager with audits and action plans, supervisions and implementing and monitoring documentation to aid continuous improvement of the Home. The manager has now completed a new named nurse list and now is displayed in the nurse’s office. The deputy manager and manager to effectively monitor care plan evaluations and risk assessment when nurses are unable to due to unforeseen circumstances such as sickness. Upon reflection, new strategies and monitoring systems have been implanted. Resident of the day has been implemented with feedback from all departments to ensure accurate reflection of person- centred care and avoidance of missed evaluations in the future. Supervisions have now been allocated to head of departments and a matrix is now available for view in nurses offices. A new daily task folder has also been implemented for the nurses to complete. This contains allocated audits (i.e care plan audits and resident of the day). This system has proven to be successful so far as anomalies have already been identified and action plan has been updated to reflect the service improvement plan
3. The manager has identified the failings of the court orders to supply documentation. has stated that this was not intentional and genuinely upset that she misunderstood the reports sent.
She now understands the importance of reading these reports thoroughly and sending requested documentation as a matter of urgency. has now returned to Cole Valley Nursing Home full time and will remain at her primary home to ensure that these measures are maintained to a high standard and ensure emails are checked daily and respond more efficiently.
Nominated Individual
Prevention of Future Deaths Notice Response 24th May 2021
To whom it may concern
1. Manager to conduct internal investigations to all falls and attach action plans. All falls and incidents to be reported on the weekly manager’s report and submitted to Nominated Individual.
2. The Manager has reviewed current documentation regarding post falls reporting and observing. The manager agrees that post documentation protocols was not substantial and did not accurately reflect the observations that took place on the day, so has implemented a new robust post falls protocol folder for the nursing team. This is allocated in one place and therefore nurses can easily access documents. This protocol now gives guidance and clear directions to follow. This protocol also has a NEWS chart that is included within this pack and a timed observation log post fall. Regarding the previous fall, the manager has reviewed archived documentation but is unable to locate any documentation to support the reported proceeding fall on or around the 15th October
2021. The manager has spoken to about this concern. said he was extremely nervous about this situation and had many anxiety attacks before attending Coroner’s Court. stated he that he panicked throughout the questioning and was not completely sure about the fall around this time. The manager has however, implemented a new manager’s report/handover for nurses to complete daily and every night. The manager to review handover daily. A Daily Walkabout Form is also in place. This identifies if there has been any accidents or incidents in the last 24 hours and what actions have been done, such as evaluating care needs of the individual involved. Cole Valley Nursing Home has promoted an RGN to Deputy Manager with supernumerary time to assist the manager with audits and action plans, supervisions and implementing and monitoring documentation to aid continuous improvement of the Home. The manager has now completed a new named nurse list and now is displayed in the nurse’s office. The deputy manager and manager to effectively monitor care plan evaluations and risk assessment when nurses are unable to due to unforeseen circumstances such as sickness. Upon reflection, new strategies and monitoring systems have been implanted. Resident of the day has been implemented with feedback from all departments to ensure accurate reflection of person- centred care and avoidance of missed evaluations in the future. Supervisions have now been allocated to head of departments and a matrix is now available for view in nurses offices. A new daily task folder has also been implemented for the nurses to complete. This contains allocated audits (i.e care plan audits and resident of the day). This system has proven to be successful so far as anomalies have already been identified and action plan has been updated to reflect the service improvement plan
3. The manager has identified the failings of the court orders to supply documentation. has stated that this was not intentional and genuinely upset that she misunderstood the reports sent.
She now understands the importance of reading these reports thoroughly and sending requested documentation as a matter of urgency. has now returned to Cole Valley Nursing Home full time and will remain at her primary home to ensure that these measures are maintained to a high standard and ensure emails are checked daily and respond more efficiently.
Nominated Individual
Report Sections
Investigation and Inquest
On 10 December 2020 I commenced an investigation into the death of Raymond Alfred POWELL. The investigation concluded at the end of the inquest.
Circumstances of the Death
Raymond had become increasingly frail and fell in August 2020 fracturing his neck of humorous and went to live at Cole Valley Nursing Home on 28 September 2020. He was assessed as being at high risk of falling and his care plan and risk assessment identified practical measures to minimise his risk of falling, including half hourly observations and when mobilising it was agreed he would use a walking frame assisted by two carers. On 3 November at around 3.30am he shouted for help and was found on the floor in his bedroom and reported pain to his head. He was assessed by paramedics and remained at the nursing home. Around 10.30am carers responded to a sensor mat alarm and found him on the floor having apparently fallen out of a chair. He was admitted to the Queen Elizabeth Hospital where a CT scan revealed the fall(s) had caused a subdural haematoma which was treated conservatively. On 19 November he developed an infection and on 22 November suffered a seizure and it was confirmed the subdural bleed had worsened. He remained very poorly and passed away on 5 December 2020. Based on information from the Deceased’s treating clinicians the medical cause of death was determined to be: 1a Acute subdural haematoma; 1b Fall; and II Diabetes mellitus. The conclusion was Raymond's death was as a consequence of an accident.
Similar PFD Reports
Reports sharing organisations, categories, or themes with this PFD
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Improve perinatal mortality recording
Morecambe Bay Investigation
Inaccurate and inaccessible patient records
Detainee Capture and Condition Records
Al-Sweady Inquiry
Inaccurate and inaccessible patient records
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.