Norman Baxter
PFD Report
All Responded
Ref: 2020-0098
All 1 response received
· Deadline: 16 Jun 2020
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
16 Jun 2020
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 AI summary
No specific concerns were detailed in the provided text for this report beyond a general statement of risk.
Responses
Response received
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Dear Mr Christopher Morris
I am in receipt of your email and Regulation 28 report.
I wish to advise that following the Inquest, a discussion between myself and
the previous manager took place and the following was put into place with immediate effect.
1. The News Scoring System
2. NEWS 2 Chart 1,2,3 (observation chart),and 4
3. Algorithm for managing suspected sepsis in adults and young people aged 18 years and over, outside an acute hospital setting. Sepsis risk stratisfication tool
4. Sepsis guidance implementation advice for adults
This was followed up by one to one discussions with all our Nursing staff confirming their understanding and how to use the tools.
the acting manager has also been made aware of the contents of the Regulation 28 report and I wish to confirm that these tools are being used and that any new nursing staff recruited since have also been made aware. Any agency staff that work at Lynmere are also advised of the use of these tools and their importance.
If I or my Manager, can be of any further assistance please do not hesitate to contact us.
Kind Regards
RMD Care Services Ltd t/a Lynmere Nursing Home
I am in receipt of your email and Regulation 28 report.
I wish to advise that following the Inquest, a discussion between myself and
the previous manager took place and the following was put into place with immediate effect.
1. The News Scoring System
2. NEWS 2 Chart 1,2,3 (observation chart),and 4
3. Algorithm for managing suspected sepsis in adults and young people aged 18 years and over, outside an acute hospital setting. Sepsis risk stratisfication tool
4. Sepsis guidance implementation advice for adults
This was followed up by one to one discussions with all our Nursing staff confirming their understanding and how to use the tools.
the acting manager has also been made aware of the contents of the Regulation 28 report and I wish to confirm that these tools are being used and that any new nursing staff recruited since have also been made aware. Any agency staff that work at Lynmere are also advised of the use of these tools and their importance.
If I or my Manager, can be of any further assistance please do not hesitate to contact us.
Kind Regards
RMD Care Services Ltd t/a Lynmere Nursing Home
Action Should Be Taken
1. The court heard evidence that, at the time Mr Baxter was cared for at Lynmere, nursing observation charts were not in use. Nursing observation charts, when completed, may assist staff in appreciating an acute episode of illness, or deterioration in a resident’s condition. This may particularly be the case were the observation chart to be used in conjunction with a system such as NEWS2, an aggregate scoring system intended to standardise the assessment of, and response to, acute illness.
Report Sections
Investigation and Inquest
On 28th August 2019, Alison Mutch OBE, Senior Coroner for Manchester South, opened an inquest into the death of Norman Baxter, who died at Stepping Hill Hospital Stockport on 8th August 2019 aged 87 years. The coronial investigation concluded with the inquest which I heard on 18th and 21st February 2020. At inquest, it was determined Mr Baxter died as a consequence of
1) a) Severe sepsis and septic shock b) Infective exacerbation of Chronic Obstructive Pulmonary Disease and e-coli infection of unconfirmed origin. II) Type 2 diabetes, probable myeloma, previous hip fracture resulting in girdlestone procedure. The inquest concluded with a narrative conclusion, to the effect that Mr Baxter died as a consequence of complications of Chronic Obstructive Pulmonary Disease and an e-coli infection. Whilst this is a natural cause of death, it is likely his death was contributed to in part by a previous hip fracture sustained in hospital which ultimately required a girdlestone procedure.
1) a) Severe sepsis and septic shock b) Infective exacerbation of Chronic Obstructive Pulmonary Disease and e-coli infection of unconfirmed origin. II) Type 2 diabetes, probable myeloma, previous hip fracture resulting in girdlestone procedure. The inquest concluded with a narrative conclusion, to the effect that Mr Baxter died as a consequence of complications of Chronic Obstructive Pulmonary Disease and an e-coli infection. Whilst this is a natural cause of death, it is likely his death was contributed to in part by a previous hip fracture sustained in hospital which ultimately required a girdlestone procedure.
Copies Sent To
law. the Care Quality Commission and Stockport MBC
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.