Gloria Linton
PFD Report
All Responded
Ref: 2024-0661
All 1 response received
· Deadline: 27 Jan 2025
Coroner's Concerns (AI summary)
Carers repeatedly failed to use a mandated transfer aid (Rotanda), contravening the care plan and previous instructions. This non-compliance resulted in improper patient positioning and injury.
View full coroner's concerns
(1) The care plan in place for Gloria required her to be transferred between sitting and standing by two carers using a piece of equipment called a Rotanda.
(2) Prior to the events of 06/08/2022 it had been noted and reported that carers were not routinely using the Rotanda, and it had been reiterated to carers by the relevant Community Health Trust that the Rotanda should be used, notwithstanding Gloria’s reluctance.
(3) On 06/08/2022 the carers did not use the Rotanda either to support Gloria to stand so she could be dried and her skin moisturised or to assist her to sit back on the commode when her bowels opened as she was being dried.
(4) Had the Rotanda been used to assist Gloria to sit, it is unlikely that she would have been placed on the commode seat at an angle such that her legs could have passed through the opening at the front of the commode seat.
(5) The carers were employed by Lifeway Care Ltd.
(2) Prior to the events of 06/08/2022 it had been noted and reported that carers were not routinely using the Rotanda, and it had been reiterated to carers by the relevant Community Health Trust that the Rotanda should be used, notwithstanding Gloria’s reluctance.
(3) On 06/08/2022 the carers did not use the Rotanda either to support Gloria to stand so she could be dried and her skin moisturised or to assist her to sit back on the commode when her bowels opened as she was being dried.
(4) Had the Rotanda been used to assist Gloria to sit, it is unlikely that she would have been placed on the commode seat at an angle such that her legs could have passed through the opening at the front of the commode seat.
(5) The carers were employed by Lifeway Care Ltd.
Responses
Action Taken
Lifeway Care provided additional training to staff on adhering to care plans and using prescribed equipment, and implemented a banner on their online app reminding carers to follow care plans and use prescribed equipment. They also stated that spot checks and refresher training will continue. (AI summary)
Lifeway Care provided additional training to staff on adhering to care plans and using prescribed equipment, and implemented a banner on their online app reminding carers to follow care plans and use prescribed equipment. They also stated that spot checks and refresher training will continue. (AI summary)
View full response
Dear Mr Longstaff, Inquest into the death of Gloria Linton - Regulation 28 Report to Prevent Future Deaths – Response by Lifeway Care Limited This response is provided to Mr Oliver Longstaff, Area Coroner for West Yorkshire on behalf of Lifeway Care Limited following the inquest into the death of Mrs Gloria Linton. Coroner's concerns The Coroner's concerns dated 2 December 2024 were as follows:
1. The care plan in place for Gloria required her to be transferred between sitting and standing by two carers using a piece of equipment called a Rotanda.
2. Prior to the events of 6 August 2022 it had been noted and reported that carers were not routinely using the Rotanda, and it had been reiterated to carers by the relevant Community Health Trust that the Rotanda should be used, notwithstanding Gloria's reluctance.
3. On 6 August 2022 the carers did not use the Rotanda either to support Gloria to stand so she could be dried and her skin moisturised or to assist her to sit back on the commode when her bowels opened as she was being dried.
4. Had the Rotanda been used to assist Gloria to sit, it is unlikely that she would have been placed on the commode seat at an angle such that her legs could have passed through the opening at the front of the commode seat.
5. The carers were employed by Lifeway Care Ltd. Response - Action taken As the Coroner is aware, immediately following the incident, all carers were provided with a refresher course in Moving and Handling, as well as refresher training on Safeguarding, Effective Communication and Reporting concerns to the Registered Manager/Office. Since the Inquest into the death of Mrs Linton, further training has been carried out with all staff in order to ensure that carers strictly adhere to care plans with regards to prescribed equipment in the future and do not use their own discretion or judgment to determine whether or not a piece of equipment ought to be used (regardless of any desire to fulfil a service user's wishes which may involve not using prescribed equipment or any determination by the carer that it would be the safer option not use a prescribed piece of equipment). The attached "Staff Declaration of Compliance with Care Plan and Equipment Use" document details the additional training that has been provided in this regard. It has been signed off by all staff to acknowledge their understanding and commitment to the use of prescribed equipment. Any new staff will be provided with this training. In addition to the additional training provided to staff, Lifeway Care Limited has also arranged via its online monitoring system providers for a banner to be inserted to the top of the online app used by its carers. This means that each time a carer attends a care visit and accesses the app, they are reminded of the following message "Attention: ensure you follow care plan and use prescribed equipment in all situations". As was the case prior to the Inquest into the death of Gloria Linton, Lifeway Care Limited will continue to carry out regular spot checks to ensure compliance with all its policies, including adherence to the use of prescribed equipment. It will also ensure that refresher training is provided regularly in the future. We trust that the above action taken by Lifeway Care Limited has satisfied the Coroner's concerns but should the Coroner have any further queries, please do not hesitate to contact us.
1. The care plan in place for Gloria required her to be transferred between sitting and standing by two carers using a piece of equipment called a Rotanda.
2. Prior to the events of 6 August 2022 it had been noted and reported that carers were not routinely using the Rotanda, and it had been reiterated to carers by the relevant Community Health Trust that the Rotanda should be used, notwithstanding Gloria's reluctance.
3. On 6 August 2022 the carers did not use the Rotanda either to support Gloria to stand so she could be dried and her skin moisturised or to assist her to sit back on the commode when her bowels opened as she was being dried.
4. Had the Rotanda been used to assist Gloria to sit, it is unlikely that she would have been placed on the commode seat at an angle such that her legs could have passed through the opening at the front of the commode seat.
5. The carers were employed by Lifeway Care Ltd. Response - Action taken As the Coroner is aware, immediately following the incident, all carers were provided with a refresher course in Moving and Handling, as well as refresher training on Safeguarding, Effective Communication and Reporting concerns to the Registered Manager/Office. Since the Inquest into the death of Mrs Linton, further training has been carried out with all staff in order to ensure that carers strictly adhere to care plans with regards to prescribed equipment in the future and do not use their own discretion or judgment to determine whether or not a piece of equipment ought to be used (regardless of any desire to fulfil a service user's wishes which may involve not using prescribed equipment or any determination by the carer that it would be the safer option not use a prescribed piece of equipment). The attached "Staff Declaration of Compliance with Care Plan and Equipment Use" document details the additional training that has been provided in this regard. It has been signed off by all staff to acknowledge their understanding and commitment to the use of prescribed equipment. Any new staff will be provided with this training. In addition to the additional training provided to staff, Lifeway Care Limited has also arranged via its online monitoring system providers for a banner to be inserted to the top of the online app used by its carers. This means that each time a carer attends a care visit and accesses the app, they are reminded of the following message "Attention: ensure you follow care plan and use prescribed equipment in all situations". As was the case prior to the Inquest into the death of Gloria Linton, Lifeway Care Limited will continue to carry out regular spot checks to ensure compliance with all its policies, including adherence to the use of prescribed equipment. It will also ensure that refresher training is provided regularly in the future. We trust that the above action taken by Lifeway Care Limited has satisfied the Coroner's concerns but should the Coroner have any further queries, please do not hesitate to contact us.
Sent To
- Lifeway Care Ltd
Response Status
Linked responses
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56-Day Deadline
27 Jan 2025
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 30/08/2022 I commenced an investigation into the death of Gloria Linton, aged 77. The investigation concluded at the end of the Inquest on 28/11/2024. The conclusion of the Inquest was a narrative conclusion, recording the cause of death as 1a) Pneumonia 1b) Rib fractures due to entrapment in a commode 2) Covid 19 infection, Cerebrovascular Disease, Ischaemic Heart Disease, Osteoporosis, Oropharyngeal Dysphagia (Clinical Diagnosis), and stating in summary that Gloria Linton died from the effects of medical complications arising from bilateral fractures of the posterior and lateral aspects of her ribs after she had become trapped in the aperture of a commode seat while being tended by carers.
Circumstances of the Death
On 06/08/2022 carers had taken Gloria Linton in a wheeled commode into her wet room, where she had toileted and been showered while still seated in the commode. Carers assisted her to stand using manual handling techniques so that she could be dried and have moisturising and barrier creams applied to her. Gloria began to open her bowels again and carers attempted to sit her down on the commode, placing her on the commode seat at an angle such that her left leg passed through the gap at the front of the commode seat and her right leg followed, effectively trapping her in the commode seat’s central aperture. She passed further down into the aperture, becoming trapped just below her chest. While trapped she sustained numerous osteoporotic fractures to the back and sides of both her ribcages, through either or both of her own efforts to free herself and the process of being extracted from the commode by the attending emergency services. The rib fractures were found at post mortem to have been a direct contributing cause of the pneumonia that was the immediate cause of Gloria’s death in hospital on 23/08/2022.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.