Doris Urch
PFD Report
All Responded
Ref: 2023-0302
All 1 response received
· Deadline: 1 Nov 2023
Coroner's Concerns (AI summary)
The care home's risk assessment process was inadequate, lacking specific recommendations and not updated after falls. Staff were unfamiliar with care plans, and the system failed to preserve historical records.
View full coroner's concerns
(1) The Question and Answer tickbox form for Risk Assessment seemed to me to leave much to be desired. It was excessively binary and meant that those who filled it in did not need to “engage” with the particular patient.
(2) The Risk Assessment did not make no recommendations or suggestions as to what to do about the risks identified.
(3) Staff seemed unfamiliar with the risk assessment/care plan, which I consider more of a systemic problem. It is unclear if/when care plans were reviewed by staff.
(4) The care plan/risk assessment was not updated in light of a fall in November/December 2022. I was concerned that potentially significant developments might not be being taken into account in keeping the care plan under review.
(5) The system does not preserve old care plans in their contemporaneous format which is a serious shortcoming which has the potential to hinder future investigations. I encourage that system to be reviewed.
(2) The Risk Assessment did not make no recommendations or suggestions as to what to do about the risks identified.
(3) Staff seemed unfamiliar with the risk assessment/care plan, which I consider more of a systemic problem. It is unclear if/when care plans were reviewed by staff.
(4) The care plan/risk assessment was not updated in light of a fall in November/December 2022. I was concerned that potentially significant developments might not be being taken into account in keeping the care plan under review.
(5) The system does not preserve old care plans in their contemporaneous format which is a serious shortcoming which has the potential to hinder future investigations. I encourage that system to be reviewed.
Responses
Action Taken
Staff training on PCS handheld devices has been implemented during induction, and a list of residents at high risk of falls is maintained to inform staff, with documentation being regularly checked for accuracy. They state that all staff are up to date with training except new employee's. (AI summary)
Staff training on PCS handheld devices has been implemented during induction, and a list of residents at high risk of falls is maintained to inform staff, with documentation being regularly checked for accuracy. They state that all staff are up to date with training except new employee's. (AI summary)
View full response
Action Plan to Prevent Future Deaths Directors:
(Quality Assurance) Manager Name:
Date: Areas of Concern:
1. Question & Answer tick box for risk assessments on the PCS system we use within our care homes
2. Risk assessments not making recommendations when risks have been identified
3. Staff being unfamiliar with care plans and risk assessment
4. Care plans and risk assessments not being updated
5. PCS system not preserving old care plans/risk assessments and reviewing the system in place. Discussions:
1. We have been using the PCS system (Person Centered Software) in all of care homes. Any risk assessments are person centered around the resident to identify risks.
2. We have checked with PCS and although risk assessments are archived residents care plans are not. This is due to care plans being reviewed on a monthly basis if not sooner depending on if circumstances change with that resident.
3. All staff use a handheld device where they have access to residents care plans and risk assessments. This will be part of our action plan to ensure that during inductions staff are shown how to access information on residents and use the devices effectively.
4. All care plans and risk assessments are reviewed and updated monthly.
5. As care plans are reviewed and updated regularly to reflect residents support we fill that it works effectively as the information on care plans are up to date. Action Plan:
The prevention of future deaths in care facilities requires adherence to strict safety protocols and procedures. Here are some key measures we have taken to reduce the risk of future deaths:
1. Staff training and supervision: Ensure that all staff members undergo rigorous training and are aware of the correct procedures for providing care and Completion Date:
Training and supervisions: All staff are up to date with training except new employee’s who complete mandatory training before starting in their post and then they have 12 weeks to complete the rest of their training schedule.
Care plans and risk assessments are reviewed monthly but sooner if changes
responding to emergencies. Regularly assess and update staff knowledge and skills. Provide adequate staffing levels to ensure proper supervision and monitoring of residents.
2. Risk assessment: Conduct regular assessments of residents to identify any potential risks to their health and safety. This includes assessing their physical and mental health needs, as well as their mobility and potential risks such as falls or wandering.
3. Safeguarding procedures: Implement robust safeguarding procedures to protect residents from abuse, neglect, or exploitation. Encourage staff to report any concerns or suspected incidents promptly. Conduct thorough investigations and take appropriate action when incidents are reported.
4. We have implemented training on the PCS handheld devices during induction for staff. This will give all new members of the team the knowledge and skills on how to use the device correctly and effectively.
5. We have implemented a list of residents who are high risk of falls to ensure that not only our regular staff and new staff but also agency staff know who are potentially at risk of harm
6.Documentation will be checked on a regular basis to ensure staff are documenting correctly and effectively. need to be made to support residents. This will continue to be ongoing in the future.
Staff are aware that any safeguarding concerns need to be reported to the manager straight away so that correct procedures are followed. This is ongoing.
All staff have been trained on how to use the PCS device and where to find all relevant information on residents. This also includes agency staff and new employees. PCS training has been added to our induction programme for new staff.
All staff have access to a list of residents who are potentially at high risk of harm. The list is updated as and when and will continue to be ongoing.
Manger, Deputy Manager, Team leaders check documentation regularly and inform staff members if they need more detailed documentation. This is ongoing.
(Quality Assurance) Manager Name:
Date: Areas of Concern:
1. Question & Answer tick box for risk assessments on the PCS system we use within our care homes
2. Risk assessments not making recommendations when risks have been identified
3. Staff being unfamiliar with care plans and risk assessment
4. Care plans and risk assessments not being updated
5. PCS system not preserving old care plans/risk assessments and reviewing the system in place. Discussions:
1. We have been using the PCS system (Person Centered Software) in all of care homes. Any risk assessments are person centered around the resident to identify risks.
2. We have checked with PCS and although risk assessments are archived residents care plans are not. This is due to care plans being reviewed on a monthly basis if not sooner depending on if circumstances change with that resident.
3. All staff use a handheld device where they have access to residents care plans and risk assessments. This will be part of our action plan to ensure that during inductions staff are shown how to access information on residents and use the devices effectively.
4. All care plans and risk assessments are reviewed and updated monthly.
5. As care plans are reviewed and updated regularly to reflect residents support we fill that it works effectively as the information on care plans are up to date. Action Plan:
The prevention of future deaths in care facilities requires adherence to strict safety protocols and procedures. Here are some key measures we have taken to reduce the risk of future deaths:
1. Staff training and supervision: Ensure that all staff members undergo rigorous training and are aware of the correct procedures for providing care and Completion Date:
Training and supervisions: All staff are up to date with training except new employee’s who complete mandatory training before starting in their post and then they have 12 weeks to complete the rest of their training schedule.
Care plans and risk assessments are reviewed monthly but sooner if changes
responding to emergencies. Regularly assess and update staff knowledge and skills. Provide adequate staffing levels to ensure proper supervision and monitoring of residents.
2. Risk assessment: Conduct regular assessments of residents to identify any potential risks to their health and safety. This includes assessing their physical and mental health needs, as well as their mobility and potential risks such as falls or wandering.
3. Safeguarding procedures: Implement robust safeguarding procedures to protect residents from abuse, neglect, or exploitation. Encourage staff to report any concerns or suspected incidents promptly. Conduct thorough investigations and take appropriate action when incidents are reported.
4. We have implemented training on the PCS handheld devices during induction for staff. This will give all new members of the team the knowledge and skills on how to use the device correctly and effectively.
5. We have implemented a list of residents who are high risk of falls to ensure that not only our regular staff and new staff but also agency staff know who are potentially at risk of harm
6.Documentation will be checked on a regular basis to ensure staff are documenting correctly and effectively. need to be made to support residents. This will continue to be ongoing in the future.
Staff are aware that any safeguarding concerns need to be reported to the manager straight away so that correct procedures are followed. This is ongoing.
All staff have been trained on how to use the PCS device and where to find all relevant information on residents. This also includes agency staff and new employees. PCS training has been added to our induction programme for new staff.
All staff have access to a list of residents who are potentially at high risk of harm. The list is updated as and when and will continue to be ongoing.
Manger, Deputy Manager, Team leaders check documentation regularly and inform staff members if they need more detailed documentation. This is ongoing.
Sent To
- Globe Court Care Home
Response Status
Linked responses
1 of 1
56-Day Deadline
1 Nov 2023
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
Report Sections
Investigation and Inquest
On 3 March 2023 the Senior Coroner, Mary Hassell, commenced an investigation into the death of Doris Urch aged 90 years. The investigation concluded at the end of the inquest on 27 July 2023.
The Inquest found that on 6th February 2023 Ms Urch fell, after her carer omitted to offer her support whilst ambulating. The risk of falls had been inadequately addressed in the Risk Assessment documentation and procedure. Although the Deceased appeared not to be seriously injured in the wake of the accident it was later confirmed on CT scan that she had suffered a brain injury, from which she later died
I returned a narrative conclusion in the following terms:
On 28th February 2023 Ms Urch died from an intracranial haemorrhage sustained in a fall on 6th February 2023, after her carer omitted to offer support whilst ambulating.
The medical cause of death was
1a Acute left frontal intracranial haemorrhage 2 Alzheimer’s Dementia
The Inquest found that on 6th February 2023 Ms Urch fell, after her carer omitted to offer her support whilst ambulating. The risk of falls had been inadequately addressed in the Risk Assessment documentation and procedure. Although the Deceased appeared not to be seriously injured in the wake of the accident it was later confirmed on CT scan that she had suffered a brain injury, from which she later died
I returned a narrative conclusion in the following terms:
On 28th February 2023 Ms Urch died from an intracranial haemorrhage sustained in a fall on 6th February 2023, after her carer omitted to offer support whilst ambulating.
The medical cause of death was
1a Acute left frontal intracranial haemorrhage 2 Alzheimer’s Dementia
Circumstances of the Death
Doris Irene Urch, aged 90, suffered from Alzheimer's dementia, and age related macular degeneration, and was known to have a high risk of falls.
I was told by , from whom I heard evidence, that the most risky transition was from standing to sitting and that during this transfer the Deceased, due to her visual impairment, would often miss the seat and fall. It was “part of her” which I took to mean an inherent and constant risk. , the care home manager, candidly accepted that “we all knew you had to watch Doris when she sits down”.
On 6th Mrs Urch was in the lounge of Globe House when she became distressed, lost her balance and fell.
It is clear that Ms Urch was not being supervised or assisted by the only carer present, , who was “sitting…with the other residents”. acknowledged that this was a mistake.
She was taken to Hospital where a CT scan evinced a large acute left frontal intracranial haemorrhage with extensive longstanding cerebral atrophy. It was decided that surgical intervention was not in her best interests and the focus shifted to palliative care.
She passed away on 28th February 2023 at around 03:30 hours.
I was told by , from whom I heard evidence, that the most risky transition was from standing to sitting and that during this transfer the Deceased, due to her visual impairment, would often miss the seat and fall. It was “part of her” which I took to mean an inherent and constant risk. , the care home manager, candidly accepted that “we all knew you had to watch Doris when she sits down”.
On 6th Mrs Urch was in the lounge of Globe House when she became distressed, lost her balance and fell.
It is clear that Ms Urch was not being supervised or assisted by the only carer present, , who was “sitting…with the other residents”. acknowledged that this was a mistake.
She was taken to Hospital where a CT scan evinced a large acute left frontal intracranial haemorrhage with extensive longstanding cerebral atrophy. It was decided that surgical intervention was not in her best interests and the focus shifted to palliative care.
She passed away on 28th February 2023 at around 03:30 hours.
Copies Sent To
, aunt of Irene Urch
Care Quality Commission for England
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Healthcare trust risk information visibility
Southport Inquiry
Inaccurate and inaccessible patient records
Amend GLOS to allow claimants oral submissions at panel hearings
Post Office Horizon Inquiry
Care risk assessment failures
Post Office to engage in negotiations during HSSA appeal period
Post Office Horizon Inquiry
Care risk assessment failures
Require multidimensional risk assessments throughout operations
Jermaine Baker Inquiry
Care risk assessment failures
Amend firearms authorisation forms for risk assessment and tipping points
Jermaine Baker Inquiry
Care risk assessment failures
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.