Terence Burns
PFD Report
All Responded
Ref: 2023-0243
All 1 response received
· Deadline: 8 Sep 2023
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Response Status
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56-Day Deadline
8 Sep 2023
All responses received
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Source: Courts and Tribunals Judiciary
Coroner's Concerns
The evidence in this case was that Mr Burns had a history of food aspiration, and following an assessment by the SALT team, he was placed on bended diet. The written care plan that was in place at Highgrove Rest Home did not contain the information that Mr Burns required a blended diet. Having heard the oral evidence from the two carers who attended the inquest to give evidence, I accepted that Mr Burns was being fed a blended diet in advance of his attendance at hospital on 28 October 2022. I found that the monthly reviews of the care plan, that were carried out on 4 September and 8 October 2022, did not amend the care plan to include the need for a blended diet, and accordingly the written care plan did not accurately define the nutritional needs of Mr Burns. This missing information from the care plan was a concern for me as the documentary evidence relating to the nutritional requirements of Mr Burns was not correct. Furthermore, I was concerned that the oral evidence that I heard at the inquest, established that the documents handed over to North West Ambulance Services when Mr Burns was taken to hospital, were not checked . When Mr Burns was taken to hospital, it could not be ascertained what information was sent with Mr Burns to enable the hospital to meet his care needs. I found that these matters gave rise to a risk of further death 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
Highgrove Rest Home implemented new procedures, including weekly checks of hospital passports by two senior staff, monthly care plan updates, and a hospital passport checklist. They also engaged with North West Ambulance Service regarding the checklist and are currently implementing digital care records with staff training.
AI summary
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Introduction: Following tne tragic death of TB and tne subsequent Coroner s inquesl, it was ordered tha: WC; the resident's care providcr submit our plan of necassaty actlons In orderto elimlnate the risk of future such occurence: cherefore set Dut Eclow cur itinerary of acticnstakon thoce actians which are currently in progras $ arid @uf proposed futurc acticns Although systems and processes viorc in place or the updating of carc plans and hospital passnorts Vie acknowledge that in this very Cc these wvere not followed,beciuse ofthis a moro robusi sys,tem was implemented Thasc areas follaws: Actions taken Hospital passports aro checked by Iwo members of senict staff weekly: Care Plans updated monthly Or when any changos t0 care are required by a senior member ol management Implementatlon of hospital passnorl cnecklist Northwvest Ambulance sorvicc (0 #ign hospital checklist to say infarmatlon nas been passed OvUI Provider contactod Northv e t Ambulance Service t0 discus: hospital checklist implemionted dlue t0 ambulance staff being reluctant to sign reccipt ofthe Gocuments, meeting held with Stuart Hall NWAS; Alison Ricchiuti Fylde Coast Care Homo Lcad and Lisa Wright Care Home Admintlralor [0 discuss: Actions currently taken Digital Care Records are in the proces ; of belng Implemented; Staff ,rt currently being trained in the use of the digital carc system Sonior management inputting all residents' details to cnsura €ancise accurate information is inputtco thist cnecked by a sccand nersan We have signed up t0 Reglstered Managcrs Foruin [0 snare viewys and information to imprave cur service: Future actlons See attached documient outlining the suggested implementatlon of "Urgont transfer (ram care home t0 hospital" document Concluslon: It is my sincere belef that with the implemcntation aftne above listed actions there is a minimur likelitocd of the recurrenco of the Lype of death suffcrcd by aur resident; TB beliavc tnat where there is more than one agency involved in Ihe care of a resident from carc hornc; Ic Is vitally important that all parties act collaboratively to ensure the safoly and wellbeing of(rat resident As illustrated above belleve tho Initiative [o be jointly undortaken between ourselvns other care providers and tha local ambulance service provides critical assurances regarding the salely of residents Tha other measures which We have undertakcn contribute # gnlficantly towards the mnirurnisation of risk similarly: In summjra believe that by the implementation of each ofthe actians as set out Jbove we provide maximum .1<urance of the safety t0 cur residents particularly at tho most vulnorable moments: The lessons Icarred Irom this tragic ovcnt are #ubstantial; and bclleve that we have nowaddre,sed each aspect of risk althuugn we continue t0 leain and react accorcingly and appropriatey "Sad aro being
Report Sections
Investigation and Inquest
On 10 July 2023, at an inquest held at Blackpool Town Hall, I returned a short form conclusion that Mr Terence Burns died as a result of misadventure. I found the cause of death to be: 1 (a) Choking ii Bronchopneumonia and brain infarct
Circumstances of the Death
I returned the following in box 3 of the Record of Inquest recorded: Mr Terence Burns was resident at the Highgrove Rest Home, Blackpool. The care plan that was put in place for Mr Burns included that he required a blended food diet. On 28 October 2022, Mr Burns' physical condition deteriorated and an ambulance was called to the Highgrove Rest Home. When Mr Burns was transferred to Blackpool Victoria Hospital, his dietary requirements were not notified to North West Ambulance Services. Consequently, during his course of treatment, the dietary requirements for Mr Burns were not known by Blackpool Victoria Hospital. During the evening of 28 October 2022, Mr Burns was given a sandwich to eat at Blackpool Victoria Hospital. At approximately 22.52hrs on 28 October 2022, Mr Burns was found unresponsive in the hospital cubicle with food reside in his throat. Mr Burns displayed no breathing effort and died at approximately 23.00hrs.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.