Richard Shannon
PFD Report
All Responded
Ref: 2022-0392
All 7 responses received
· Deadline: 30 Jan 2023
Coroner's Concerns (AI summary)
Critical communication breakdowns during hospital discharge led to a failure in securing a pressure-relieving bed and a lack of clear instructions for daily skin integrity checks by district nurses and carers, exacerbated by social services missing key risk information.
View full coroner's concerns
1. The discharge team at University College Hospital (UCH) did not seek a pressure relieving bed and mattress to replace Professor Shannon’s own before he was discharged on 5 January.
This was because his sacral pressure ulcer was almost fully healed and so they did not consider it necessary. However, he was at risk of further pressure ulcers and so it was a measure that should have been sought. The changing of a bed is more difficult to organise once the patient is home and sleeping in it.
If the Central London Community Healthcare district nursing team at Soho Centre for Health and Care (the district nurses) had been invited and had attended the UCH discharge planning meeting, it is much more likely that this measure would have been considered.
2. Upon discharge, UCH sent a referral to the district nurses. This included notification of a grade 2 pressure ulcer and a high risk of pressure ulcers in the future. Professor Shannon had three significant risk factors. He was immobile, he had diabetes, and he had already suffered a pressure ulcer.
The UCH nurses expected the district nurses to check the skin integrity every day. The district nurses did not intend to include this in their daily tasks when they attended the home to assist with insulin administration for diabetic control and with catheter care.
If the district nurses had been invited and had attended the UCH discharge planning meeting, this misunderstanding could easily have been identified and the true position understood by all.
3. The district nurses expected the carers employed by Kapital Care UK Limited (the Kapital carers) and commissioned by social services at the City of Westminster Council (social services) to check the skin integrity every day. However, there is no record that they issued such an instruction.
Even if individual district nurses had sought to issue such an instruction to Kapital carers, the district nurses only attended the home once a day and did not always meet the carers. When the nurses did meet the carers, they rarely saw the same carer twice. Individual district nurses could not ensure that such an instruction was issued to all carers who attended Professor Shannon. This instruction had to be given at a higher level and passed on to each and every Kapital carer.
4. Upon discharge, a Discharge to Assess form was completed by therapists (I am unclear whether occupational or physiotherapists) at UCH and sent to social services at the City of Westminster. The form raised a number of concerns, but did not specifically instruct that carers should check skin integrity every day. That was an omission.
5. The City of Westminster social worker considering the Discharge to Assess form did not consider any part of the form other than the specific instructions. She did not include in her thinking the record a little further down the same page that Professor Shannon had a grade 2 pressure ulcer and was at high risk of developing pressure ulcers.
She told me that she was a social worker and not medically trained to read the Discharge to Assess form. However, she accepted that the form clearly stated that Professor Shannon had a grade 2 pressure ulcer and was at high risk of pressure ulcers.
She said that she did not issue a specific instruction to Kapital to check skin integrity every day.
6. When a district nurse arrived at the home the morning after discharge, she found that Professor Shannon’s catheter bag was so full it had become detached, and he had demonstrably and significantly soiled himself.
He had been in this condition when a Kapital carer had visited earlier that same morning, but the carer had not cleaned him or changed the catheter bag.
It took the district nurse three hours properly to take care of her patient’s needs. Carers from Kapital had been booked to visit Professor Shannon’s home for an hour four times each day by the City of Westminster. One of their specific tasks was to attend to the personal hygiene needs of this elderly and vulnerable man who was unable to attend to them himself.
The Kapital carer’s explanation for leaving him in this condition was that there was no soap or towel in the property. This excuse struck me as demonstrating an appalling lack of humanity and I was shocked to hear of it. In fact, Professor Shannon was obviously dearly loved, and his friends had done everything they could do to make his home ready for him, including stocking his bathroom with soap and towels readily found by the district nurse. Apparently, the Kapital carer had simply not opened the bathroom cupboard.
7. The City of Westminster undertook a safeguarding investigation after Professor Shannon’s death.
In that investigation, intended to learn lessons for the benefit of others, the City of Westminster investigator accepted, as the social worker had at the time, the explanation given by Kapital that the towels had been brought to the property after the carer’s first visit that morning and therefore had not been available to the carer. The investigator did not interview the Kapital carer. He accepted at inquest that he should have done.
There was no evidence to support Kapital’s assertion and it was in fact completely inaccurate.
8. The safeguarding investigation was concluded by the social worker from Westminster at the end of June 2022, but I was told that there have been no changes made to systems or training in the intervening five months. The social worker has recently emailed partner agencies suggesting a meeting, but no such meeting has taken place.
Apparently, no lessons have been learnt.
9. What struck me most forcibly throughout the inquest touching the death of Richard Shannon, was that lots of professionals were charged with his care, lots of professionals attended his home, lots of professional met him, yet still very basic elements of his needs were omitted. Despite all the resources expended, he was not cared for as a whole person.
In 2022, we must be able to expect better for those in need.
This was because his sacral pressure ulcer was almost fully healed and so they did not consider it necessary. However, he was at risk of further pressure ulcers and so it was a measure that should have been sought. The changing of a bed is more difficult to organise once the patient is home and sleeping in it.
If the Central London Community Healthcare district nursing team at Soho Centre for Health and Care (the district nurses) had been invited and had attended the UCH discharge planning meeting, it is much more likely that this measure would have been considered.
2. Upon discharge, UCH sent a referral to the district nurses. This included notification of a grade 2 pressure ulcer and a high risk of pressure ulcers in the future. Professor Shannon had three significant risk factors. He was immobile, he had diabetes, and he had already suffered a pressure ulcer.
The UCH nurses expected the district nurses to check the skin integrity every day. The district nurses did not intend to include this in their daily tasks when they attended the home to assist with insulin administration for diabetic control and with catheter care.
If the district nurses had been invited and had attended the UCH discharge planning meeting, this misunderstanding could easily have been identified and the true position understood by all.
3. The district nurses expected the carers employed by Kapital Care UK Limited (the Kapital carers) and commissioned by social services at the City of Westminster Council (social services) to check the skin integrity every day. However, there is no record that they issued such an instruction.
Even if individual district nurses had sought to issue such an instruction to Kapital carers, the district nurses only attended the home once a day and did not always meet the carers. When the nurses did meet the carers, they rarely saw the same carer twice. Individual district nurses could not ensure that such an instruction was issued to all carers who attended Professor Shannon. This instruction had to be given at a higher level and passed on to each and every Kapital carer.
4. Upon discharge, a Discharge to Assess form was completed by therapists (I am unclear whether occupational or physiotherapists) at UCH and sent to social services at the City of Westminster. The form raised a number of concerns, but did not specifically instruct that carers should check skin integrity every day. That was an omission.
5. The City of Westminster social worker considering the Discharge to Assess form did not consider any part of the form other than the specific instructions. She did not include in her thinking the record a little further down the same page that Professor Shannon had a grade 2 pressure ulcer and was at high risk of developing pressure ulcers.
She told me that she was a social worker and not medically trained to read the Discharge to Assess form. However, she accepted that the form clearly stated that Professor Shannon had a grade 2 pressure ulcer and was at high risk of pressure ulcers.
She said that she did not issue a specific instruction to Kapital to check skin integrity every day.
6. When a district nurse arrived at the home the morning after discharge, she found that Professor Shannon’s catheter bag was so full it had become detached, and he had demonstrably and significantly soiled himself.
He had been in this condition when a Kapital carer had visited earlier that same morning, but the carer had not cleaned him or changed the catheter bag.
It took the district nurse three hours properly to take care of her patient’s needs. Carers from Kapital had been booked to visit Professor Shannon’s home for an hour four times each day by the City of Westminster. One of their specific tasks was to attend to the personal hygiene needs of this elderly and vulnerable man who was unable to attend to them himself.
The Kapital carer’s explanation for leaving him in this condition was that there was no soap or towel in the property. This excuse struck me as demonstrating an appalling lack of humanity and I was shocked to hear of it. In fact, Professor Shannon was obviously dearly loved, and his friends had done everything they could do to make his home ready for him, including stocking his bathroom with soap and towels readily found by the district nurse. Apparently, the Kapital carer had simply not opened the bathroom cupboard.
7. The City of Westminster undertook a safeguarding investigation after Professor Shannon’s death.
In that investigation, intended to learn lessons for the benefit of others, the City of Westminster investigator accepted, as the social worker had at the time, the explanation given by Kapital that the towels had been brought to the property after the carer’s first visit that morning and therefore had not been available to the carer. The investigator did not interview the Kapital carer. He accepted at inquest that he should have done.
There was no evidence to support Kapital’s assertion and it was in fact completely inaccurate.
8. The safeguarding investigation was concluded by the social worker from Westminster at the end of June 2022, but I was told that there have been no changes made to systems or training in the intervening five months. The social worker has recently emailed partner agencies suggesting a meeting, but no such meeting has taken place.
Apparently, no lessons have been learnt.
9. What struck me most forcibly throughout the inquest touching the death of Richard Shannon, was that lots of professionals were charged with his care, lots of professionals attended his home, lots of professional met him, yet still very basic elements of his needs were omitted. Despite all the resources expended, he was not cared for as a whole person.
In 2022, we must be able to expect better for those in need.
Responses
Action Taken
Kapital Care has implemented actions including contacting district nurses for care arrangements, completing robust handovers with previous care providers, requesting all relevant assessments and information regarding the adult, ensuring they have the relevant discharge notification form, identifying any potential conflict of interest when interviewing staff, and ensuring robust and timely communication. (AI summary)
Kapital Care has implemented actions including contacting district nurses for care arrangements, completing robust handovers with previous care providers, requesting all relevant assessments and information regarding the adult, ensuring they have the relevant discharge notification form, identifying any potential conflict of interest when interviewing staff, and ensuring robust and timely communication. (AI summary)
View full response
Dear Coroner, Hassell
We write to provide you with a detailed response to the Regulation 28 report dated 5th December 2022 regarding the death of Mr Richard Shannon on 19th February
2022. We have worked together in an integrated way across the organisations involved in Professor Shannon’s care to provide a thorough response covering all nine areas of concern raised in your report, as relevant across the agencies. Several changes to practice and procedure have already taken place since the safeguarding enquiry outcome meeting on 16th June 2022 and we are each committed to continuing to implement learning and improvements highlighted. This includes both within our individual organisations and between our organisations to improve the co-ordination and communication of care arrangements for our residents and patients which is of paramount importance to us.
Kapital care have implemented the following actions in relation to the relevant concerns raised in the preventions of future death report (PFD). A review of all policies and procedure was completed/or is currently in progress since the completion of the safeguarding enquiry and your report. Concern 3
• Kapital care coordinators will contact district nurses in all cases when it is identified they are involved in the adult’s care arrangements. This will ensure any care and support needs relating to pressure ulcer management and other relevant care needs can be implemented as part of our care plans.
• A robust handover is completed with any previous care provider.
• Kapital care requests all relevant assessments & information regarding the adult from relevant professionals involved in the care, including Physio, OT, DN’s and GP. This includes telephone numbers of who to contact in an emergency.
• Kapital care will request additional training from CNWL academy for our care staff, whereby specific needs are identified relating to pressure ulcers management and repositioning.
• All care staff currently complete mandatory pressure ulcer management training. This has since been reviewed and staff will complete refresher training where appropriate.
• Care staff complete body maps of any pressure area concerns. All identified concerns will/are reported to district nurses, adult social care or GP.
• Kapital Care have met with commissioners and safeguarding leads to understand and take action on where improvements are needed.
Kapital Care (UK) Limited 1 Crowndale Road, Camden, London NW1 1TU Tel: 0203 904 4393 / 07960052571 Email: enquiries@kapitalcare.co.uk Web: www.kapitalcare.co.uk
▪ Page 2 ▪ ▪ Kapital Care (UK) Ltd ▪ Company No. 10153700 ▪ 1Crowndale Road, Camden, London NW1 1UT▪
In association with:
• Kapital Care will immediately escalate any concerns or issues to the Local Authority.
Concern 5
• All relevant information including hospital discharge notes for the client is reviewed to ensure a better understanding of a person’s care needs.
• Kapital care reviews the discharge letter sent home with the adult to identify any additional needs relevant to the care delivery.
• Following the Coroner’s report Kapital have met with CNWL/CLCH and other partner agencies. CNWL/CLCH has agreed to share appropriate information with Kapital care via the new discharge notification process.
• Kapital care will immediately contact adult social care to request any care plans are updated, whereby additional care needs are identified as part of the initial visit/risk assessment.
• Kapital Care will immediately escalate any concerns or issues to the Local Authority.
Concern 6
• Review of all policies and procedure has been completed/in progress since the safeguarding enquiry/Coroner report which include the actions set out.
• Review of all training needs for all care staff employed by Kapital care to identify training needs across the organization and improve standards of care.
• Kapital care will complete a robust manual handling assessment, including mobility equipment and environmental assessment are completed by the care coordinator prior/during the initial visit. This will ensure appropriate equipment, including items used to maintain the adults personal care is available within the property.
• All care staff will escalate their concerns to the care coordinator whilst at the adult’s home if they are unable to complete or deliver essential personal care tasks due to the lack of equipment in place. Kapital care will ensure the issue is resolved before the care staff leave the property and ensure the adults hygiene and dignity is always maintained. This action will prevent a reoccurrence of the identified concern.
• Any concerns identified which impact on our ability to complete the care tasks are reported immediately to adult social care, ensuring an immediate solution is found.
• Review the care plan when any concerns are raised/identified.
• Review of recording and documentation within the organisation.
• Care coordinators will facilitate joint visits with adult social care or other relevant professionals when a concern is identified.
Kapital Care (UK) Limited 1 Crowndale Road, Camden, London NW1 1TU Tel: 0203 904 4393 / 07960052571 Email: enquiries@kapitalcare.co.uk Web: www.kapitalcare.co.uk
▪ Page 3 ▪ ▪ Kapital Care (UK) Ltd ▪ Company No. 10153700 ▪ 1Crowndale Road, Camden, London NW1 1UT▪
In association with:
• Kapital care will ensure they have the relevant discharge notification form prior to commencing a hospital discharge care package.
Concern 7
• Kapital care maintains full cooperation with the local authority in all safeguarding enquiries. Since the Coroner’s report Kapital care has identified any potential conflict of interest when interviewing our own care staff. This is to be discussed with the local authority to identify who is the most appropriate person/agency to lead the interview. Concern 8
• Kapital care participated fully with the safeguarding enquiry relating to Professor Shannon. Kapital care attended the enquiry outcome meetings and noted the identified learning for our organisation.
• Kapital have implemented the actions and identified learning following the safeguarding enquiry and most recent Coroner’s report. Concern 9
• Kapital care will ensure the implemented actions and identified learning as detailed within this report are maintained and reviewed regularly. These actions will ensure close partnership working with all agencies involved in an individual care arrangement.
• Kapital care is ensuring robust and timely communication is undertaken with all agencies.
Conclusion Kapital Care (UK) are committed to safeguarding adults with care and support needs. Our policy sets out the roles and responsibilities of Kapital Care in working together with other professionals and agencies in promoting the adult’s welfare and safeguarding. We remain committed to fully adhering to meeting service objectives and to continue to raise concerns as appropriate. Within our continuous improvement plan, we will continue to ensure our procedures remain effective and pro-active where possible, to identify any other gaps, with a view to ensuring any further preventative measures are built in them and ensure the dignity of adults in our care are maintained to the highest standards.
Registered Branch Manage
We write to provide you with a detailed response to the Regulation 28 report dated 5th December 2022 regarding the death of Mr Richard Shannon on 19th February
2022. We have worked together in an integrated way across the organisations involved in Professor Shannon’s care to provide a thorough response covering all nine areas of concern raised in your report, as relevant across the agencies. Several changes to practice and procedure have already taken place since the safeguarding enquiry outcome meeting on 16th June 2022 and we are each committed to continuing to implement learning and improvements highlighted. This includes both within our individual organisations and between our organisations to improve the co-ordination and communication of care arrangements for our residents and patients which is of paramount importance to us.
Kapital care have implemented the following actions in relation to the relevant concerns raised in the preventions of future death report (PFD). A review of all policies and procedure was completed/or is currently in progress since the completion of the safeguarding enquiry and your report. Concern 3
• Kapital care coordinators will contact district nurses in all cases when it is identified they are involved in the adult’s care arrangements. This will ensure any care and support needs relating to pressure ulcer management and other relevant care needs can be implemented as part of our care plans.
• A robust handover is completed with any previous care provider.
• Kapital care requests all relevant assessments & information regarding the adult from relevant professionals involved in the care, including Physio, OT, DN’s and GP. This includes telephone numbers of who to contact in an emergency.
• Kapital care will request additional training from CNWL academy for our care staff, whereby specific needs are identified relating to pressure ulcers management and repositioning.
• All care staff currently complete mandatory pressure ulcer management training. This has since been reviewed and staff will complete refresher training where appropriate.
• Care staff complete body maps of any pressure area concerns. All identified concerns will/are reported to district nurses, adult social care or GP.
• Kapital Care have met with commissioners and safeguarding leads to understand and take action on where improvements are needed.
Kapital Care (UK) Limited 1 Crowndale Road, Camden, London NW1 1TU Tel: 0203 904 4393 / 07960052571 Email: enquiries@kapitalcare.co.uk Web: www.kapitalcare.co.uk
▪ Page 2 ▪ ▪ Kapital Care (UK) Ltd ▪ Company No. 10153700 ▪ 1Crowndale Road, Camden, London NW1 1UT▪
In association with:
• Kapital Care will immediately escalate any concerns or issues to the Local Authority.
Concern 5
• All relevant information including hospital discharge notes for the client is reviewed to ensure a better understanding of a person’s care needs.
• Kapital care reviews the discharge letter sent home with the adult to identify any additional needs relevant to the care delivery.
• Following the Coroner’s report Kapital have met with CNWL/CLCH and other partner agencies. CNWL/CLCH has agreed to share appropriate information with Kapital care via the new discharge notification process.
• Kapital care will immediately contact adult social care to request any care plans are updated, whereby additional care needs are identified as part of the initial visit/risk assessment.
• Kapital Care will immediately escalate any concerns or issues to the Local Authority.
Concern 6
• Review of all policies and procedure has been completed/in progress since the safeguarding enquiry/Coroner report which include the actions set out.
• Review of all training needs for all care staff employed by Kapital care to identify training needs across the organization and improve standards of care.
• Kapital care will complete a robust manual handling assessment, including mobility equipment and environmental assessment are completed by the care coordinator prior/during the initial visit. This will ensure appropriate equipment, including items used to maintain the adults personal care is available within the property.
• All care staff will escalate their concerns to the care coordinator whilst at the adult’s home if they are unable to complete or deliver essential personal care tasks due to the lack of equipment in place. Kapital care will ensure the issue is resolved before the care staff leave the property and ensure the adults hygiene and dignity is always maintained. This action will prevent a reoccurrence of the identified concern.
• Any concerns identified which impact on our ability to complete the care tasks are reported immediately to adult social care, ensuring an immediate solution is found.
• Review the care plan when any concerns are raised/identified.
• Review of recording and documentation within the organisation.
• Care coordinators will facilitate joint visits with adult social care or other relevant professionals when a concern is identified.
Kapital Care (UK) Limited 1 Crowndale Road, Camden, London NW1 1TU Tel: 0203 904 4393 / 07960052571 Email: enquiries@kapitalcare.co.uk Web: www.kapitalcare.co.uk
▪ Page 3 ▪ ▪ Kapital Care (UK) Ltd ▪ Company No. 10153700 ▪ 1Crowndale Road, Camden, London NW1 1UT▪
In association with:
• Kapital care will ensure they have the relevant discharge notification form prior to commencing a hospital discharge care package.
Concern 7
• Kapital care maintains full cooperation with the local authority in all safeguarding enquiries. Since the Coroner’s report Kapital care has identified any potential conflict of interest when interviewing our own care staff. This is to be discussed with the local authority to identify who is the most appropriate person/agency to lead the interview. Concern 8
• Kapital care participated fully with the safeguarding enquiry relating to Professor Shannon. Kapital care attended the enquiry outcome meetings and noted the identified learning for our organisation.
• Kapital have implemented the actions and identified learning following the safeguarding enquiry and most recent Coroner’s report. Concern 9
• Kapital care will ensure the implemented actions and identified learning as detailed within this report are maintained and reviewed regularly. These actions will ensure close partnership working with all agencies involved in an individual care arrangement.
• Kapital care is ensuring robust and timely communication is undertaken with all agencies.
Conclusion Kapital Care (UK) are committed to safeguarding adults with care and support needs. Our policy sets out the roles and responsibilities of Kapital Care in working together with other professionals and agencies in promoting the adult’s welfare and safeguarding. We remain committed to fully adhering to meeting service objectives and to continue to raise concerns as appropriate. Within our continuous improvement plan, we will continue to ensure our procedures remain effective and pro-active where possible, to identify any other gaps, with a view to ensuring any further preventative measures are built in them and ensure the dignity of adults in our care are maintained to the highest standards.
Registered Branch Manage
Action Taken
Central London Community Healthcare NHS Trust has enhanced communication with University College Hospital NHS Trust by setting up a specific phone number and time for discussing hospital discharges, and set up monthly review meetings. Learning from the incident has been shared with staff, and safeguarding concerns will automatically trigger an internal escalation to the safeguarding team. They have also strengthened discharge planning processes. (AI summary)
Central London Community Healthcare NHS Trust has enhanced communication with University College Hospital NHS Trust by setting up a specific phone number and time for discussing hospital discharges, and set up monthly review meetings. Learning from the incident has been shared with staff, and safeguarding concerns will automatically trigger an internal escalation to the safeguarding team. They have also strengthened discharge planning processes. (AI summary)
View full response
Dear Ms Hassell
I write to provide you with our response to the Regulation 28 report dated 5th December 2022 related to the sad death of Professor Richard Shannon on 19th February 2022.
We have worked together across the organisations involved in Professors Shannon’s care to provide a response covering all nine areas of concern raised in your report, as relevant across the agencies. Subsequent to the safeguarding enquiry outcome meeting which was held on 16th June 2022, a number of changes to practice have taken place and we are committed to ensuring the improvements highlighted, both within our individual organisations and across our organisations are maintained moving forward.
We would like to take this opportunity to offer our sincere condolences to Professor Shannon’s family, friends and those who knew him. We acknowledge and welcome the findings of the inquest and recognise that some of the care that Professor Shannon received fell below the standards we would expect, and for this we are sorry.
Regulation 28: Matters of Concern Actioned by Central London Community Healthcare NHS Trust
Concern 1: This concern related to discharge planning and the need for Central London Community Healthcare NHS Trust Community Nurses to be invited to discharge planning meetings.
Following the inquest, we have met with colleagues at University College Hospital NHS Trust and have agreed steps to improve our current working arrangements in relation to discharge planning.
Actions completed
• We have enhanced lines of communication between out teams, by setting up a specific phone number and time when the nurses will be able to discuss hospital discharges.
• We have set up monthly review meetings with University College Hospital NHS Trust and partners to ensure the partnership working continues to develop and improve.
• The District Nurses are now invited to meetings with University College Hospital NHS Trust for any complex discharges.
- 2 - Concern 2: Avoiding misunderstanding regarding care being provided by different providers could easily have been identified during discharge planning and the true position understood by all, if Central London Community Healthcare NHS Trust had been invited to the meeting.
We acknowledge that collaboration with partners during discharge planning would have ensured better continuity of care. The ability of Central London Community Healthcare NHS Trust’s Community Nurses and staff from the Central North West London NHS Foundation Trust Community Independent Service to access and read each other’s records when delivering care helped enhance communication between the two services; However, we have now taken further steps to strengthen communication across the system.
Actions completed
• All communications including care plans are now being shared with all providers involved in care at discharge to ensure consistency in care provision.
• We are working with the Safeguarding Adults Executive Board to embed change and provide assurance regarding the safe discharge of adults at risk from all hospitals across the system.
Concern 3: The district nurses expected the carers employed by Kapital Care UK Limited to check the skin integrity every day. However, there is no record that they issued such an instruction.
Action completed
• We have updated the care plans template for care plans that are held in the patients’ home to ensure that they contain clear instructions for the carers where required. This documentation now also includes clear escalation criteria and contact details for the community nurses.
Concern 4. Upon discharge, a Discharge to Assess form was completed by therapists. The form raised a number of concerns but did not specifically instruct that carers should check skin integrity every day. That was an omission.
Action completed
• The Central London Community Healthcare NHS Trust District Nursing Team has worked with University College Hospital NHS Trust and the City of Westminster to review and improve the quality of information we share with carers, prior to a vulnerable adult being discharged from hospital. This includes giving clear instructions regarding holistic care requirements and the equipment needed to reduce the risk of pressure damage.
Concerns 5: The City of Westminster social worker considering the Discharge to Assess form did not include in her thinking that Professor Shannon had a grade 2 pressure ulcer and was at high risk of developing pressure ulcers
Central London Community Healthcare NHS Trust continues to work with other organisations through the Safeguarding Adults Executive Board with its focus on the prevention of pressure ulcers.
Actions completed
• To further enhance the level of pressure ulcer prevention knowledge in the local system, we have shared our pressure ulcer care training proforma from the Central London Community Healthcare NHS Trust Academy with Westminster adult social care to assist in ensuring that there is a clear standard of training delivered by the different care organisations which will support carers to deliver effective care.
- 3 -
• Central London Community Healthcare NHS Trust Academy will also offer further training where it is required to care organisations
Concern 6: When the District Nurse visited Professor Shannon the day after his discharge, his catheter bag was so full it had come detached, and he was demonstrably soiled. Our Community Nurse did raise her concerns with the care agency and social worker about the soiled condition she found Professor Shannon. An internal incident report was completed by the Community Nurse. However, we acknowledge there was a missed opportunity to raise a safeguarding concern with the local authority.
Action completed
• We have shared learning from this with staff involved and across the organization to ensure that such an incident will automatically trigger an internal escalation to our safeguarding team in the Trust who will follow this up with the local authority.
Concern 9: Professor Shannon was not cared for as a whole person Action completed
• We have enhanced our overall communication with system partners and strengthened our discharge planning processes which has improved our overall planning and coordination of care needs, that will ensure all our patients receive holistic care.
Progress against all agreed and completed actions will be reviewed at our Divisional Quality forums on the 13th February and again on the 13th March 2023. Assurance will also be provided to our Patient Safety Risk group on 29th March 2023 to ensure all the agreed actions have been completed and improvements fully embedded.
We will continue to work collaboratively through the safeguarding processes to further embed improvements outlined above and agreed with our system partners to strengthen partnership working and discharge planning to enable holistic and personalized care to be delivered.
In addition, CLCH will ensure the changes to practice are embedded in operational procedures for all our community teams and this work will be completed by 31st March 2023.
Finally in my role as Chief Nursing Officer for the NW London ICB I will ensure their learning is shared with all providers of Community Nursing Services.
I write to provide you with our response to the Regulation 28 report dated 5th December 2022 related to the sad death of Professor Richard Shannon on 19th February 2022.
We have worked together across the organisations involved in Professors Shannon’s care to provide a response covering all nine areas of concern raised in your report, as relevant across the agencies. Subsequent to the safeguarding enquiry outcome meeting which was held on 16th June 2022, a number of changes to practice have taken place and we are committed to ensuring the improvements highlighted, both within our individual organisations and across our organisations are maintained moving forward.
We would like to take this opportunity to offer our sincere condolences to Professor Shannon’s family, friends and those who knew him. We acknowledge and welcome the findings of the inquest and recognise that some of the care that Professor Shannon received fell below the standards we would expect, and for this we are sorry.
Regulation 28: Matters of Concern Actioned by Central London Community Healthcare NHS Trust
Concern 1: This concern related to discharge planning and the need for Central London Community Healthcare NHS Trust Community Nurses to be invited to discharge planning meetings.
Following the inquest, we have met with colleagues at University College Hospital NHS Trust and have agreed steps to improve our current working arrangements in relation to discharge planning.
Actions completed
• We have enhanced lines of communication between out teams, by setting up a specific phone number and time when the nurses will be able to discuss hospital discharges.
• We have set up monthly review meetings with University College Hospital NHS Trust and partners to ensure the partnership working continues to develop and improve.
• The District Nurses are now invited to meetings with University College Hospital NHS Trust for any complex discharges.
- 2 - Concern 2: Avoiding misunderstanding regarding care being provided by different providers could easily have been identified during discharge planning and the true position understood by all, if Central London Community Healthcare NHS Trust had been invited to the meeting.
We acknowledge that collaboration with partners during discharge planning would have ensured better continuity of care. The ability of Central London Community Healthcare NHS Trust’s Community Nurses and staff from the Central North West London NHS Foundation Trust Community Independent Service to access and read each other’s records when delivering care helped enhance communication between the two services; However, we have now taken further steps to strengthen communication across the system.
Actions completed
• All communications including care plans are now being shared with all providers involved in care at discharge to ensure consistency in care provision.
• We are working with the Safeguarding Adults Executive Board to embed change and provide assurance regarding the safe discharge of adults at risk from all hospitals across the system.
Concern 3: The district nurses expected the carers employed by Kapital Care UK Limited to check the skin integrity every day. However, there is no record that they issued such an instruction.
Action completed
• We have updated the care plans template for care plans that are held in the patients’ home to ensure that they contain clear instructions for the carers where required. This documentation now also includes clear escalation criteria and contact details for the community nurses.
Concern 4. Upon discharge, a Discharge to Assess form was completed by therapists. The form raised a number of concerns but did not specifically instruct that carers should check skin integrity every day. That was an omission.
Action completed
• The Central London Community Healthcare NHS Trust District Nursing Team has worked with University College Hospital NHS Trust and the City of Westminster to review and improve the quality of information we share with carers, prior to a vulnerable adult being discharged from hospital. This includes giving clear instructions regarding holistic care requirements and the equipment needed to reduce the risk of pressure damage.
Concerns 5: The City of Westminster social worker considering the Discharge to Assess form did not include in her thinking that Professor Shannon had a grade 2 pressure ulcer and was at high risk of developing pressure ulcers
Central London Community Healthcare NHS Trust continues to work with other organisations through the Safeguarding Adults Executive Board with its focus on the prevention of pressure ulcers.
Actions completed
• To further enhance the level of pressure ulcer prevention knowledge in the local system, we have shared our pressure ulcer care training proforma from the Central London Community Healthcare NHS Trust Academy with Westminster adult social care to assist in ensuring that there is a clear standard of training delivered by the different care organisations which will support carers to deliver effective care.
- 3 -
• Central London Community Healthcare NHS Trust Academy will also offer further training where it is required to care organisations
Concern 6: When the District Nurse visited Professor Shannon the day after his discharge, his catheter bag was so full it had come detached, and he was demonstrably soiled. Our Community Nurse did raise her concerns with the care agency and social worker about the soiled condition she found Professor Shannon. An internal incident report was completed by the Community Nurse. However, we acknowledge there was a missed opportunity to raise a safeguarding concern with the local authority.
Action completed
• We have shared learning from this with staff involved and across the organization to ensure that such an incident will automatically trigger an internal escalation to our safeguarding team in the Trust who will follow this up with the local authority.
Concern 9: Professor Shannon was not cared for as a whole person Action completed
• We have enhanced our overall communication with system partners and strengthened our discharge planning processes which has improved our overall planning and coordination of care needs, that will ensure all our patients receive holistic care.
Progress against all agreed and completed actions will be reviewed at our Divisional Quality forums on the 13th February and again on the 13th March 2023. Assurance will also be provided to our Patient Safety Risk group on 29th March 2023 to ensure all the agreed actions have been completed and improvements fully embedded.
We will continue to work collaboratively through the safeguarding processes to further embed improvements outlined above and agreed with our system partners to strengthen partnership working and discharge planning to enable holistic and personalized care to be delivered.
In addition, CLCH will ensure the changes to practice are embedded in operational procedures for all our community teams and this work will be completed by 31st March 2023.
Finally in my role as Chief Nursing Officer for the NW London ICB I will ensure their learning is shared with all providers of Community Nursing Services.
Action Taken
Kapital Care has implemented actions including contacting district nurses for care arrangements, completing robust handovers with previous care providers, requesting all relevant assessments and information regarding the adult, ensuring they have the relevant discharge notification form, identifying any potential conflict of interest when interviewing staff, and ensuring robust and timely communication. (AI summary)
Kapital Care has implemented actions including contacting district nurses for care arrangements, completing robust handovers with previous care providers, requesting all relevant assessments and information regarding the adult, ensuring they have the relevant discharge notification form, identifying any potential conflict of interest when interviewing staff, and ensuring robust and timely communication. (AI summary)
View full response
Dear Coroner, Hassell
We write to provide you with a detailed response to the Regulation 28 report dated 5th December 2022 regarding the death of Mr Richard Shannon on 19th February
2022. We have worked together in an integrated way across the organisations involved in Professor Shannon’s care to provide a thorough response covering all nine areas of concern raised in your report, as relevant across the agencies. Several changes to practice and procedure have already taken place since the safeguarding enquiry outcome meeting on 16th June 2022 and we are each committed to continuing to implement learning and improvements highlighted. This includes both within our individual organisations and between our organisations to improve the co-ordination and communication of care arrangements for our residents and patients which is of paramount importance to us.
Kapital care have implemented the following actions in relation to the relevant concerns raised in the preventions of future death report (PFD). A review of all policies and procedure was completed/or is currently in progress since the completion of the safeguarding enquiry and your report. Concern 3
• Kapital care coordinators will contact district nurses in all cases when it is identified they are involved in the adult’s care arrangements. This will ensure any care and support needs relating to pressure ulcer management and other relevant care needs can be implemented as part of our care plans.
• A robust handover is completed with any previous care provider.
• Kapital care requests all relevant assessments & information regarding the adult from relevant professionals involved in the care, including Physio, OT, DN’s and GP. This includes telephone numbers of who to contact in an emergency.
• Kapital care will request additional training from CNWL academy for our care staff, whereby specific needs are identified relating to pressure ulcers management and repositioning.
• All care staff currently complete mandatory pressure ulcer management training. This has since been reviewed and staff will complete refresher training where appropriate.
• Care staff complete body maps of any pressure area concerns. All identified concerns will/are reported to district nurses, adult social care or GP.
• Kapital Care have met with commissioners and safeguarding leads to understand and take action on where improvements are needed.
Kapital Care (UK) Limited 1 Crowndale Road, Camden, London NW1 1TU Tel: 0203 904 4393 / 07960052571 Email: enquiries@kapitalcare.co.uk Web: www.kapitalcare.co.uk
▪ Page 2 ▪ ▪ Kapital Care (UK) Ltd ▪ Company No. 10153700 ▪ 1Crowndale Road, Camden, London NW1 1UT▪
In association with:
• Kapital Care will immediately escalate any concerns or issues to the Local Authority.
Concern 5
• All relevant information including hospital discharge notes for the client is reviewed to ensure a better understanding of a person’s care needs.
• Kapital care reviews the discharge letter sent home with the adult to identify any additional needs relevant to the care delivery.
• Following the Coroner’s report Kapital have met with CNWL/CLCH and other partner agencies. CNWL/CLCH has agreed to share appropriate information with Kapital care via the new discharge notification process.
• Kapital care will immediately contact adult social care to request any care plans are updated, whereby additional care needs are identified as part of the initial visit/risk assessment.
• Kapital Care will immediately escalate any concerns or issues to the Local Authority.
Concern 6
• Review of all policies and procedure has been completed/in progress since the safeguarding enquiry/Coroner report which include the actions set out.
• Review of all training needs for all care staff employed by Kapital care to identify training needs across the organization and improve standards of care.
• Kapital care will complete a robust manual handling assessment, including mobility equipment and environmental assessment are completed by the care coordinator prior/during the initial visit. This will ensure appropriate equipment, including items used to maintain the adults personal care is available within the property.
• All care staff will escalate their concerns to the care coordinator whilst at the adult’s home if they are unable to complete or deliver essential personal care tasks due to the lack of equipment in place. Kapital care will ensure the issue is resolved before the care staff leave the property and ensure the adults hygiene and dignity is always maintained. This action will prevent a reoccurrence of the identified concern.
• Any concerns identified which impact on our ability to complete the care tasks are reported immediately to adult social care, ensuring an immediate solution is found.
• Review the care plan when any concerns are raised/identified.
• Review of recording and documentation within the organisation.
• Care coordinators will facilitate joint visits with adult social care or other relevant professionals when a concern is identified.
Kapital Care (UK) Limited 1 Crowndale Road, Camden, London NW1 1TU Tel: 0203 904 4393 / 07960052571 Email: enquiries@kapitalcare.co.uk Web: www.kapitalcare.co.uk
▪ Page 3 ▪ ▪ Kapital Care (UK) Ltd ▪ Company No. 10153700 ▪ 1Crowndale Road, Camden, London NW1 1UT▪
In association with:
• Kapital care will ensure they have the relevant discharge notification form prior to commencing a hospital discharge care package.
Concern 7
• Kapital care maintains full cooperation with the local authority in all safeguarding enquiries. Since the Coroner’s report Kapital care has identified any potential conflict of interest when interviewing our own care staff. This is to be discussed with the local authority to identify who is the most appropriate person/agency to lead the interview. Concern 8
• Kapital care participated fully with the safeguarding enquiry relating to Professor Shannon. Kapital care attended the enquiry outcome meetings and noted the identified learning for our organisation.
• Kapital have implemented the actions and identified learning following the safeguarding enquiry and most recent Coroner’s report. Concern 9
• Kapital care will ensure the implemented actions and identified learning as detailed within this report are maintained and reviewed regularly. These actions will ensure close partnership working with all agencies involved in an individual care arrangement.
• Kapital care is ensuring robust and timely communication is undertaken with all agencies.
Conclusion Kapital Care (UK) are committed to safeguarding adults with care and support needs. Our policy sets out the roles and responsibilities of Kapital Care in working together with other professionals and agencies in promoting the adult’s welfare and safeguarding. We remain committed to fully adhering to meeting service objectives and to continue to raise concerns as appropriate. Within our continuous improvement plan, we will continue to ensure our procedures remain effective and pro-active where possible, to identify any other gaps, with a view to ensuring any further preventative measures are built in them and ensure the dignity of adults in our care are maintained to the highest standards.
Registered Branch Manage
We write to provide you with a detailed response to the Regulation 28 report dated 5th December 2022 regarding the death of Mr Richard Shannon on 19th February
2022. We have worked together in an integrated way across the organisations involved in Professor Shannon’s care to provide a thorough response covering all nine areas of concern raised in your report, as relevant across the agencies. Several changes to practice and procedure have already taken place since the safeguarding enquiry outcome meeting on 16th June 2022 and we are each committed to continuing to implement learning and improvements highlighted. This includes both within our individual organisations and between our organisations to improve the co-ordination and communication of care arrangements for our residents and patients which is of paramount importance to us.
Kapital care have implemented the following actions in relation to the relevant concerns raised in the preventions of future death report (PFD). A review of all policies and procedure was completed/or is currently in progress since the completion of the safeguarding enquiry and your report. Concern 3
• Kapital care coordinators will contact district nurses in all cases when it is identified they are involved in the adult’s care arrangements. This will ensure any care and support needs relating to pressure ulcer management and other relevant care needs can be implemented as part of our care plans.
• A robust handover is completed with any previous care provider.
• Kapital care requests all relevant assessments & information regarding the adult from relevant professionals involved in the care, including Physio, OT, DN’s and GP. This includes telephone numbers of who to contact in an emergency.
• Kapital care will request additional training from CNWL academy for our care staff, whereby specific needs are identified relating to pressure ulcers management and repositioning.
• All care staff currently complete mandatory pressure ulcer management training. This has since been reviewed and staff will complete refresher training where appropriate.
• Care staff complete body maps of any pressure area concerns. All identified concerns will/are reported to district nurses, adult social care or GP.
• Kapital Care have met with commissioners and safeguarding leads to understand and take action on where improvements are needed.
Kapital Care (UK) Limited 1 Crowndale Road, Camden, London NW1 1TU Tel: 0203 904 4393 / 07960052571 Email: enquiries@kapitalcare.co.uk Web: www.kapitalcare.co.uk
▪ Page 2 ▪ ▪ Kapital Care (UK) Ltd ▪ Company No. 10153700 ▪ 1Crowndale Road, Camden, London NW1 1UT▪
In association with:
• Kapital Care will immediately escalate any concerns or issues to the Local Authority.
Concern 5
• All relevant information including hospital discharge notes for the client is reviewed to ensure a better understanding of a person’s care needs.
• Kapital care reviews the discharge letter sent home with the adult to identify any additional needs relevant to the care delivery.
• Following the Coroner’s report Kapital have met with CNWL/CLCH and other partner agencies. CNWL/CLCH has agreed to share appropriate information with Kapital care via the new discharge notification process.
• Kapital care will immediately contact adult social care to request any care plans are updated, whereby additional care needs are identified as part of the initial visit/risk assessment.
• Kapital Care will immediately escalate any concerns or issues to the Local Authority.
Concern 6
• Review of all policies and procedure has been completed/in progress since the safeguarding enquiry/Coroner report which include the actions set out.
• Review of all training needs for all care staff employed by Kapital care to identify training needs across the organization and improve standards of care.
• Kapital care will complete a robust manual handling assessment, including mobility equipment and environmental assessment are completed by the care coordinator prior/during the initial visit. This will ensure appropriate equipment, including items used to maintain the adults personal care is available within the property.
• All care staff will escalate their concerns to the care coordinator whilst at the adult’s home if they are unable to complete or deliver essential personal care tasks due to the lack of equipment in place. Kapital care will ensure the issue is resolved before the care staff leave the property and ensure the adults hygiene and dignity is always maintained. This action will prevent a reoccurrence of the identified concern.
• Any concerns identified which impact on our ability to complete the care tasks are reported immediately to adult social care, ensuring an immediate solution is found.
• Review the care plan when any concerns are raised/identified.
• Review of recording and documentation within the organisation.
• Care coordinators will facilitate joint visits with adult social care or other relevant professionals when a concern is identified.
Kapital Care (UK) Limited 1 Crowndale Road, Camden, London NW1 1TU Tel: 0203 904 4393 / 07960052571 Email: enquiries@kapitalcare.co.uk Web: www.kapitalcare.co.uk
▪ Page 3 ▪ ▪ Kapital Care (UK) Ltd ▪ Company No. 10153700 ▪ 1Crowndale Road, Camden, London NW1 1UT▪
In association with:
• Kapital care will ensure they have the relevant discharge notification form prior to commencing a hospital discharge care package.
Concern 7
• Kapital care maintains full cooperation with the local authority in all safeguarding enquiries. Since the Coroner’s report Kapital care has identified any potential conflict of interest when interviewing our own care staff. This is to be discussed with the local authority to identify who is the most appropriate person/agency to lead the interview. Concern 8
• Kapital care participated fully with the safeguarding enquiry relating to Professor Shannon. Kapital care attended the enquiry outcome meetings and noted the identified learning for our organisation.
• Kapital have implemented the actions and identified learning following the safeguarding enquiry and most recent Coroner’s report. Concern 9
• Kapital care will ensure the implemented actions and identified learning as detailed within this report are maintained and reviewed regularly. These actions will ensure close partnership working with all agencies involved in an individual care arrangement.
• Kapital care is ensuring robust and timely communication is undertaken with all agencies.
Conclusion Kapital Care (UK) are committed to safeguarding adults with care and support needs. Our policy sets out the roles and responsibilities of Kapital Care in working together with other professionals and agencies in promoting the adult’s welfare and safeguarding. We remain committed to fully adhering to meeting service objectives and to continue to raise concerns as appropriate. Within our continuous improvement plan, we will continue to ensure our procedures remain effective and pro-active where possible, to identify any other gaps, with a view to ensuring any further preventative measures are built in them and ensure the dignity of adults in our care are maintained to the highest standards.
Registered Branch Manage
Action Taken
The Trust enhanced communication lines, set up monthly review meetings with the hospital, shared learning with staff to escalate safeguarding concerns, and strengthened discharge planning processes. Progress will be reviewed at divisional quality forums, and changes will be embedded in operational procedures by March 31, 2023. (AI summary)
The Trust enhanced communication lines, set up monthly review meetings with the hospital, shared learning with staff to escalate safeguarding concerns, and strengthened discharge planning processes. Progress will be reviewed at divisional quality forums, and changes will be embedded in operational procedures by March 31, 2023. (AI summary)
View full response
Dear Ms Hassell
I write to provide you with our response to the Regulation 28 report dated 5th December 2022 related to the sad death of Professor Richard Shannon on 19th February 2022.
We have worked together across the organisations involved in Professors Shannon’s care to provide a response covering all nine areas of concern raised in your report, as relevant across the agencies. Subsequent to the safeguarding enquiry outcome meeting which was held on 16th June 2022, a number of changes to practice have taken place and we are committed to ensuring the improvements highlighted, both within our individual organisations and across our organisations are maintained moving forward.
We would like to take this opportunity to offer our sincere condolences to Professor Shannon’s family, friends and those who knew him. We acknowledge and welcome the findings of the inquest and recognise that some of the care that Professor Shannon received fell below the standards we would expect, and for this we are sorry.
Regulation 28: Matters of Concern Actioned by Central London Community Healthcare NHS Trust
Concern 1: This concern related to discharge planning and the need for Central London Community Healthcare NHS Trust Community Nurses to be invited to discharge planning meetings.
Following the inquest, we have met with colleagues at University College Hospital NHS Trust and have agreed steps to improve our current working arrangements in relation to discharge planning.
Actions completed
• We have enhanced lines of communication between out teams, by setting up a specific phone number and time when the nurses will be able to discuss hospital discharges.
• We have set up monthly review meetings with University College Hospital NHS Trust and partners to ensure the partnership working continues to develop and improve.
• The District Nurses are now invited to meetings with University College Hospital NHS Trust for any complex discharges.
- 2 - Concern 2: Avoiding misunderstanding regarding care being provided by different providers could easily have been identified during discharge planning and the true position understood by all, if Central London Community Healthcare NHS Trust had been invited to the meeting.
We acknowledge that collaboration with partners during discharge planning would have ensured better continuity of care. The ability of Central London Community Healthcare NHS Trust’s Community Nurses and staff from the Central North West London NHS Foundation Trust Community Independent Service to access and read each other’s records when delivering care helped enhance communication between the two services; However, we have now taken further steps to strengthen communication across the system.
Actions completed
• All communications including care plans are now being shared with all providers involved in care at discharge to ensure consistency in care provision.
• We are working with the Safeguarding Adults Executive Board to embed change and provide assurance regarding the safe discharge of adults at risk from all hospitals across the system.
Concern 3: The district nurses expected the carers employed by Kapital Care UK Limited to check the skin integrity every day. However, there is no record that they issued such an instruction.
Action completed
• We have updated the care plans template for care plans that are held in the patients’ home to ensure that they contain clear instructions for the carers where required. This documentation now also includes clear escalation criteria and contact details for the community nurses.
Concern 4. Upon discharge, a Discharge to Assess form was completed by therapists. The form raised a number of concerns but did not specifically instruct that carers should check skin integrity every day. That was an omission.
Action completed
• The Central London Community Healthcare NHS Trust District Nursing Team has worked with University College Hospital NHS Trust and the City of Westminster to review and improve the quality of information we share with carers, prior to a vulnerable adult being discharged from hospital. This includes giving clear instructions regarding holistic care requirements and the equipment needed to reduce the risk of pressure damage.
Concerns 5: The City of Westminster social worker considering the Discharge to Assess form did not include in her thinking that Professor Shannon had a grade 2 pressure ulcer and was at high risk of developing pressure ulcers
Central London Community Healthcare NHS Trust continues to work with other organisations through the Safeguarding Adults Executive Board with its focus on the prevention of pressure ulcers.
Actions completed
• To further enhance the level of pressure ulcer prevention knowledge in the local system, we have shared our pressure ulcer care training proforma from the Central London Community Healthcare NHS Trust Academy with Westminster adult social care to assist in ensuring that there is a clear standard of training delivered by the different care organisations which will support carers to deliver effective care.
- 3 -
• Central London Community Healthcare NHS Trust Academy will also offer further training where it is required to care organisations
Concern 6: When the District Nurse visited Professor Shannon the day after his discharge, his catheter bag was so full it had come detached, and he was demonstrably soiled. Our Community Nurse did raise her concerns with the care agency and social worker about the soiled condition she found Professor Shannon. An internal incident report was completed by the Community Nurse. However, we acknowledge there was a missed opportunity to raise a safeguarding concern with the local authority.
Action completed
• We have shared learning from this with staff involved and across the organization to ensure that such an incident will automatically trigger an internal escalation to our safeguarding team in the Trust who will follow this up with the local authority.
Concern 9: Professor Shannon was not cared for as a whole person Action completed
• We have enhanced our overall communication with system partners and strengthened our discharge planning processes which has improved our overall planning and coordination of care needs, that will ensure all our patients receive holistic care.
Progress against all agreed and completed actions will be reviewed at our Divisional Quality forums on the 13th February and again on the 13th March 2023. Assurance will also be provided to our Patient Safety Risk group on 29th March 2023 to ensure all the agreed actions have been completed and improvements fully embedded.
We will continue to work collaboratively through the safeguarding processes to further embed improvements outlined above and agreed with our system partners to strengthen partnership working and discharge planning to enable holistic and personalized care to be delivered.
In addition, CLCH will ensure the changes to practice are embedded in operational procedures for all our community teams and this work will be completed by 31st March 2023.
Finally in my role as Chief Nursing Officer for the NW London ICB I will ensure their learning is shared with all providers of Community Nursing Services.
I write to provide you with our response to the Regulation 28 report dated 5th December 2022 related to the sad death of Professor Richard Shannon on 19th February 2022.
We have worked together across the organisations involved in Professors Shannon’s care to provide a response covering all nine areas of concern raised in your report, as relevant across the agencies. Subsequent to the safeguarding enquiry outcome meeting which was held on 16th June 2022, a number of changes to practice have taken place and we are committed to ensuring the improvements highlighted, both within our individual organisations and across our organisations are maintained moving forward.
We would like to take this opportunity to offer our sincere condolences to Professor Shannon’s family, friends and those who knew him. We acknowledge and welcome the findings of the inquest and recognise that some of the care that Professor Shannon received fell below the standards we would expect, and for this we are sorry.
Regulation 28: Matters of Concern Actioned by Central London Community Healthcare NHS Trust
Concern 1: This concern related to discharge planning and the need for Central London Community Healthcare NHS Trust Community Nurses to be invited to discharge planning meetings.
Following the inquest, we have met with colleagues at University College Hospital NHS Trust and have agreed steps to improve our current working arrangements in relation to discharge planning.
Actions completed
• We have enhanced lines of communication between out teams, by setting up a specific phone number and time when the nurses will be able to discuss hospital discharges.
• We have set up monthly review meetings with University College Hospital NHS Trust and partners to ensure the partnership working continues to develop and improve.
• The District Nurses are now invited to meetings with University College Hospital NHS Trust for any complex discharges.
- 2 - Concern 2: Avoiding misunderstanding regarding care being provided by different providers could easily have been identified during discharge planning and the true position understood by all, if Central London Community Healthcare NHS Trust had been invited to the meeting.
We acknowledge that collaboration with partners during discharge planning would have ensured better continuity of care. The ability of Central London Community Healthcare NHS Trust’s Community Nurses and staff from the Central North West London NHS Foundation Trust Community Independent Service to access and read each other’s records when delivering care helped enhance communication between the two services; However, we have now taken further steps to strengthen communication across the system.
Actions completed
• All communications including care plans are now being shared with all providers involved in care at discharge to ensure consistency in care provision.
• We are working with the Safeguarding Adults Executive Board to embed change and provide assurance regarding the safe discharge of adults at risk from all hospitals across the system.
Concern 3: The district nurses expected the carers employed by Kapital Care UK Limited to check the skin integrity every day. However, there is no record that they issued such an instruction.
Action completed
• We have updated the care plans template for care plans that are held in the patients’ home to ensure that they contain clear instructions for the carers where required. This documentation now also includes clear escalation criteria and contact details for the community nurses.
Concern 4. Upon discharge, a Discharge to Assess form was completed by therapists. The form raised a number of concerns but did not specifically instruct that carers should check skin integrity every day. That was an omission.
Action completed
• The Central London Community Healthcare NHS Trust District Nursing Team has worked with University College Hospital NHS Trust and the City of Westminster to review and improve the quality of information we share with carers, prior to a vulnerable adult being discharged from hospital. This includes giving clear instructions regarding holistic care requirements and the equipment needed to reduce the risk of pressure damage.
Concerns 5: The City of Westminster social worker considering the Discharge to Assess form did not include in her thinking that Professor Shannon had a grade 2 pressure ulcer and was at high risk of developing pressure ulcers
Central London Community Healthcare NHS Trust continues to work with other organisations through the Safeguarding Adults Executive Board with its focus on the prevention of pressure ulcers.
Actions completed
• To further enhance the level of pressure ulcer prevention knowledge in the local system, we have shared our pressure ulcer care training proforma from the Central London Community Healthcare NHS Trust Academy with Westminster adult social care to assist in ensuring that there is a clear standard of training delivered by the different care organisations which will support carers to deliver effective care.
- 3 -
• Central London Community Healthcare NHS Trust Academy will also offer further training where it is required to care organisations
Concern 6: When the District Nurse visited Professor Shannon the day after his discharge, his catheter bag was so full it had come detached, and he was demonstrably soiled. Our Community Nurse did raise her concerns with the care agency and social worker about the soiled condition she found Professor Shannon. An internal incident report was completed by the Community Nurse. However, we acknowledge there was a missed opportunity to raise a safeguarding concern with the local authority.
Action completed
• We have shared learning from this with staff involved and across the organization to ensure that such an incident will automatically trigger an internal escalation to our safeguarding team in the Trust who will follow this up with the local authority.
Concern 9: Professor Shannon was not cared for as a whole person Action completed
• We have enhanced our overall communication with system partners and strengthened our discharge planning processes which has improved our overall planning and coordination of care needs, that will ensure all our patients receive holistic care.
Progress against all agreed and completed actions will be reviewed at our Divisional Quality forums on the 13th February and again on the 13th March 2023. Assurance will also be provided to our Patient Safety Risk group on 29th March 2023 to ensure all the agreed actions have been completed and improvements fully embedded.
We will continue to work collaboratively through the safeguarding processes to further embed improvements outlined above and agreed with our system partners to strengthen partnership working and discharge planning to enable holistic and personalized care to be delivered.
In addition, CLCH will ensure the changes to practice are embedded in operational procedures for all our community teams and this work will be completed by 31st March 2023.
Finally in my role as Chief Nursing Officer for the NW London ICB I will ensure their learning is shared with all providers of Community Nursing Services.
Action Taken
The Trust reviewed and improved local processes and education for staff, strengthened collaboration with community partners, and formed a monthly partnership to review progress, share learning, and collaborate on improvements to enhance the quality and safety of hospital discharge processes and care outside of the hospital. (AI summary)
The Trust reviewed and improved local processes and education for staff, strengthened collaboration with community partners, and formed a monthly partnership to review progress, share learning, and collaborate on improvements to enhance the quality and safety of hospital discharge processes and care outside of the hospital. (AI summary)
View full response
Dear Ma’am, Re: Mr Richard Shannon Prevention of Future Death report We write to provide you with a detailed response to the Regulation 28 report dated 5th December 2022, regarding the death of Professor Richard Shannon on 19th February
2022. We have worked together, in an integrated way, across the organisations involved in Professor Shannon’s care, to provide a thorough response covering all nine areas of concern raised in your report, as relevant across the agencies. Several changes to practice and procedure have already taken place since the safeguarding enquiry outcome meeting on 3rd February 2022. We are each committed to continuing to implement the learning and improvements highlighted. This includes both within our individual organisations, and between our organisations, to improve the co-ordination and communication of care arrangements for our residents and patients which is of paramount importance to us.
1 This response is made on behalf of Acting Chief Nurse, University College London Hospitals NHS Foundation Trust 2 Regulation 28 Report This response follows a report by Coroner ME Hassell on 5th December 2022 3 Investigation and inquest On 11 March 2022, I commenced an investigation into the death of Richard Thomas Shannon aged 91 years. The investigation concluded at the end of the inquest on 24 November 2022. I made a narrative determination at inquest as follows. “Professor Shannon died as a consequence of an extremely severe pressure ulcer. This developed at some point between his discharge from hospital on 5 January and his readmission on 13 January 2022, in all likelihood between 10 and 13 January. Whilst a pressure ulcer for a person with his co-morbidities (most particularly immobility and diabetes) is a natural cause of death, there was a failure properly to monitor his skin integrity in his final days.
2/6
If his skin integrity had been properly monitored and he had been appropriately treated, he would not have developed a pressure sore of that severity and would not have died.” The medical cause of death was: 1a pneumonia 1b coccyx osteomyelitis 1c infected sacral pressure ulcer 2 type II diabetes mellitus, previous stroke and previous throat cancer 4 Circumstances of the death When Professor Shannon was discharged from University College London Hospital on 5 January 2022, his sacral pressure ulcer was almost completely healed. When he was readmitted on 13 January 2022, his condition was irretrievable. His sacral pressure ulcer was now 5-6cms in diameter, covered in black, necrotic tissue, and unstageable. The infection that penetrated to the bone killed him. 5 Coroner's concerns The MATTERS OF CONCERN are as follows.
1. The discharge team at University College Hospital (UCH) did not seek a pressure relieving bed and mattress to replace Professor Shannon’s own before he was discharged on 5 January. This was because his sacral pressure ulcer was almost fully healed and so they did not consider it necessary. However, he was at risk of further pressure ulcers and so it was a measure that should have been sought. The changing of a bed is more difficult to organise once the patient is home and sleeping in it. If the Central London Community Healthcare district nursing team at Soho Centre for Health and Care (the district nurses) had been invited and had attended the UCH discharge planning meeting, it is much more likely that this measure would have been considered.
2. Upon discharge, UCH sent a referral to the district nurses. This included notification of a grade 2 pressure ulcer and a high risk of pressure ulcers in the future. Professor Shannon had three significant risk factors. He was immobile, he had diabetes, and he had already suffered a pressure ulcer. The UCH nurses expected the district nurses to check the skin integrity every day. The district nurses did not intend to include this in their daily tasks when they attended the home to assist with insulin administration for diabetic control and with catheter care. If the district nurses had been invited and had attended the UCH discharge planning meeting, this misunderstanding could easily have been identified and the true position understood by all.
3. The district nurses expected the carers employed by Kapital Care UK Limited (the Kapital carers) and commissioned by social services at the City of Westminster Council (social services) to check the skin integrity every day. However, there is no record that they issued such an instruction. Even if individual district nurses had sought to issue such an instruction to Kapital carers, the district nurses only attended the home once a day and did not always
3/6
meet the carers. When the nurses did meet the carers, they rarely saw the same carer twice. 4 Individual district nurses could not ensure that such an instruction was issued to all carers who attended Professor Shannon. This instruction had to be given at a higher level and passed on to each and every Kapital carer.
4. Upon discharge, a Discharge to Assess form was completed by therapists (I am unclear whether occupational or physiotherapists) at UCH and sent to social services at the City of Westminster. The form raised a number of concerns, but did not specifically instruct that carers should check skin integrity every day. That was an omission.
5. The City of Westminster social worker considering the Discharge to Assess form did not consider any part of the form other than the specific instructions. She did not include in her thinking the record a little further down the same page that Professor Shannon had a grade 2 pressure ulcer and was at high risk of developing pressure ulcers. She told me that she was a social worker and not medically trained to read the Discharge to Assess form. However, she accepted that the form clearly stated that Professor Shannon had a grade 2 pressure ulcer and was at high risk of pressure ulcers. She said that she did not issue a specific instruction to Kapital to check skin integrity every day.
6. When a district nurse arrived at the home the morning after discharge, she found that Professor Shannon’s catheter bag was so full it had become detached, and he had demonstrably and significantly soiled himself. He had been in this condition when a Kapital carer had visited earlier that same morning, but the carer had not cleaned him or changed the catheter bag. It took the district nurse three hours properly to take care of her patient’s needs. Carers from Kapital had been booked to visit Professor Shannon’s home for an hour four times each day by the City of Westminster. One of their specific tasks was to attend to the personal hygiene needs of this elderly and vulnerable man who was unable to attend to them himself. The Kapital carer’s explanation for leaving him in this condition was that there was no soap or towel in the property. This excuse struck me as demonstrating an appalling lack of humanity and I was shocked to hear of it. 5 In fact, Professor Shannon was obviously dearly loved, and his friends had done everything they could do to make his home ready for him, including stocking his bathroom with soap and towels readily found by the district nurse. Apparently, the Kapital carer had simply not opened the bathroom cupboard.
7. The City of Westminster undertook a safeguarding investigation after Professor Shannon’s death. In that investigation, intended to learn lessons for the benefit of others, the City of Westminster investigator accepted, as the social worker had at the time, the explanation given by Kapital that the towels had been brought to the property after the carer’s first visit that morning and therefore had not been available to the carer. The investigator did not interview the Kapital carer. He accepted at inquest that he should have done. There was no evidence to support Kapital’s assertion and it was in fact completely inaccurate.
8. The safeguarding investigation was concluded by the social worker from Westminster at the end of June 2022, but I was told that there have been no changes made to systems or training in the intervening five months. The social worker has recently emailed partner agencies suggesting a meeting, but no such meeting has taken place. Apparently, no lessons have been learnt.
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9. What struck me most forcibly throughout the inquest touching the death of Richard Shannon, was that lots of professionals were charged with his care, lots of professionals attended his home, lots of professional met him, yet still very basic elements of his needs were omitted. Despite all the resources expended, he was not cared for as a whole person. In 2022, we must be able to expect better for those in need. 6 Action taken/timescale A number of actions were taken including linking with borough partners. UCLH actions relate to concerns 1, 2, 4 and 9 and are detailed below;
1. The discharge team at University College Hospital (UCH) did not seek a pressure relieving bed and mattress to replace Professor Shannon’s own before he was discharged on 5 January. Actions:
• The Tissue Viability (TV) team at UCLH now document their reviews on the discharge planning section of the patient’s electronic health record system (Epic). This was previously completed under another section of the patient notes. This change ensures that the discharge team has a holistic view of the patient’s need, including skin concerns / risks and requests for equipment/dressings/skin checks, prior to discharge. This in turn ensures improved communication of risk, from UCLH discharge team to our community and social care partners.
• Registered nurses will be trained to add nursing notes (pertinent to discharge and continuity of care), on the discharge summaries on Epic . This has been completed for the senior staff nurses working in the ward (care of older people), where Professor Shannon was a patient. This training has been evaluated and will now be rolled out to specific wards across all hospital sites that link with community and social care partners. This will be review quarterly and reported quarterly through the Harm-free Care Committee and the Nursing and Midwifery Board (chaired by the Chief Nurse). The Trust Patient Safety Committee (PSC) will also be updated on a quarterly basis.
• North Central London (NCL) Integrated Care Board (ICB) has developed a NCL tissue viability passport which is designed to be a consistent tool for recording and communicating information about pressure ulcers at the point of discharge and within the community. UCLH discharge and tissue viability teams have contributed to the development of the tool. The tissue viability passport form will be used across NCL hospitals, when signed off by the NCL ICB senior management team. Once finalised, this form will be embedded into the UCLH’s Epic system for hospital use.
• UCLH has liaised with Central London Community Health (CLCH) to improve links with district nurses. The UCLH discharge team now has the phone number of the district nurses and know that between 2-4pm Monday-Friday, the team will be available to discuss any discharges.
• We have set up monthly review meetings with CLCH to ensure the partnership working continues to develop and improve including, enhancing UCLH’s understanding of the district nurse role. This will also include joint education and training, to better understand roles and responsibilities and reduce silo working and gaps in care.
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• The district nurses have agreed that they will attend meetings with UCLH for any complex patient discharges.
• Westminster City Council has agreed to base a social worker in UCLH to improve communication and joint working across health and social care. This started on 23rd January 2023
• Following discussion with the Islington Transfer of Care Hub Clinical Screener, all referrals should be screened to ensure that the skin section and all nursing sections are completed by the therapist/referrer, prior to them being sent to the community partners. This is the expected process which will be further communicated to staff to ensure clinical information is highlighted and an appropriate care plan identified.
2. Upon discharge, UCLH sent a referral to the district nurses. This included notification of a grade 2 pressure ulcer and a high risk of pressure ulcers in the future. The UCH nurses expected the district nurses to check the skin integrity every day. The district nurses did not intend to include this in their daily tasks when they attended the home to assist with insulin administration for diabetic control and with catheter care. Actions:
• UCLH has liaised with Central London Community Health (CLCH) to improve links with district nurses. The UCLH discharge team now has the phone number of the district nurses and know that between 2-4pm Monday-Friday the team will be available to discuss any discharges.
• We have set up monthly review meetings with CLCH to ensure the partnership working continues to develop and improve including enhancing UCLH’s understanding of the District Nurse role.
• The district nurses have agreed that they will attend meetings with UCLH for any complex discharges.
4. Upon discharge, a Discharge to Assess form was completed by therapists at UCLH and sent to social services at the City of Westminster. The form raised a number of concerns, but did not specifically instruct that carers should check skin integrity every day. That was an omission. Actions:
• Pressure ulcer training for therapists has commenced in the ward where Professor Shannon was a patient. This includes understanding of the causes and risk factors for pressure ulcers to ensure information/instructions in relation to skin care and risk is communicated clearly on the discharge to assess forms. Regular drop-in teaching sessions continue, as well as planned sessions to ensure all therapists in the trust have had this training by the end of June 2023. This training will be evaluated and reported via the Harm-free Care Committee and the Nursing and Midwifery Board (chaired by the Chief Nurse).
9. What struck me most forcibly throughout the inquest touching the death of Richard Shannon, was that lots of professionals were charged with his care, lots of professionals
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att e n d e d hi s h o m e, l ot s of pr of e s si o n al m et hi m, y et still v er y b a si c el e m e nt s of hi s n e e d s w er e o mitt e d. D e s pit e all t h e r e s o ur c e s e x p e n d e d, h e w a s n ot c ar e d f or a s a w h ol e p er s o n. I n 2 0 2 2, w e m u st b e a bl e t o e x p e ct b ett er f or t h o s e i n n e e d. A cti o n s: W e h a v e r e vi e w e d a n d i m pr o v e d o ur l o c al pr o c e s s e s a n d e d u c ati o n f or st aff t o pr e v e nt f urt h er p o or o ut c o m e s f or p ati e nt s. T hi s i s si g nifi c a ntl y str e n gt h e n e d b y w or ki n g c oll a b or ati v el y wit h o ur p art n er s i n t h e c o m m u nit y a n d s o ci al c ar e. W e ar e c o nfi d e nt t hi s i m pr o v e d a p pr o a c h will e n h a n c e t h e q u alit y a n d s af et y of t h e h o s pit al di s c h ar g e pr o c e s s a n d c ar e o ut si d e of h o s pit al . W e ar e c o nfi d e nt t h at w e h a v e a d dr e s s e d t h e c o n c er n s r ai s e d t o e n s ur e t h e c ar e w e pr o vi d e t o p ati e nt s i s s af e a n d h oli sti c . T o a s s ur e o ur s el v e s a n d ot h er s , w e h a v e a gr e e d t o m e et m o nt hl y a s a n e wl y f or m e d p ar t n er s hi p t o r e vi e w pr o gr e s s a g ai n st t h e s e a cti o n s, s h ar e l e ar ni n g a n d c oll a b or at e o n i m pr o v e m e nt s.
7 T hi s r e s p o n s e h a s b e e n pr e p ar e d b y D e p ut y C hi ef N ur s e 8 D at e of r e s p o n s e 2 4 t h J a n u ar y 2 0 2 3
Y o ur s si n c er el y ,
C hi ef N ur s e ( A cti n g)
c c: C at h y M o o n e y, Dir e ct or f or Q u alit y a n d S af et y, U C L H
K at h ari n e K a n d el a ki, Cl ai m s & I n q u e st s M a n a g er, U C L H
2022. We have worked together, in an integrated way, across the organisations involved in Professor Shannon’s care, to provide a thorough response covering all nine areas of concern raised in your report, as relevant across the agencies. Several changes to practice and procedure have already taken place since the safeguarding enquiry outcome meeting on 3rd February 2022. We are each committed to continuing to implement the learning and improvements highlighted. This includes both within our individual organisations, and between our organisations, to improve the co-ordination and communication of care arrangements for our residents and patients which is of paramount importance to us.
1 This response is made on behalf of Acting Chief Nurse, University College London Hospitals NHS Foundation Trust 2 Regulation 28 Report This response follows a report by Coroner ME Hassell on 5th December 2022 3 Investigation and inquest On 11 March 2022, I commenced an investigation into the death of Richard Thomas Shannon aged 91 years. The investigation concluded at the end of the inquest on 24 November 2022. I made a narrative determination at inquest as follows. “Professor Shannon died as a consequence of an extremely severe pressure ulcer. This developed at some point between his discharge from hospital on 5 January and his readmission on 13 January 2022, in all likelihood between 10 and 13 January. Whilst a pressure ulcer for a person with his co-morbidities (most particularly immobility and diabetes) is a natural cause of death, there was a failure properly to monitor his skin integrity in his final days.
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If his skin integrity had been properly monitored and he had been appropriately treated, he would not have developed a pressure sore of that severity and would not have died.” The medical cause of death was: 1a pneumonia 1b coccyx osteomyelitis 1c infected sacral pressure ulcer 2 type II diabetes mellitus, previous stroke and previous throat cancer 4 Circumstances of the death When Professor Shannon was discharged from University College London Hospital on 5 January 2022, his sacral pressure ulcer was almost completely healed. When he was readmitted on 13 January 2022, his condition was irretrievable. His sacral pressure ulcer was now 5-6cms in diameter, covered in black, necrotic tissue, and unstageable. The infection that penetrated to the bone killed him. 5 Coroner's concerns The MATTERS OF CONCERN are as follows.
1. The discharge team at University College Hospital (UCH) did not seek a pressure relieving bed and mattress to replace Professor Shannon’s own before he was discharged on 5 January. This was because his sacral pressure ulcer was almost fully healed and so they did not consider it necessary. However, he was at risk of further pressure ulcers and so it was a measure that should have been sought. The changing of a bed is more difficult to organise once the patient is home and sleeping in it. If the Central London Community Healthcare district nursing team at Soho Centre for Health and Care (the district nurses) had been invited and had attended the UCH discharge planning meeting, it is much more likely that this measure would have been considered.
2. Upon discharge, UCH sent a referral to the district nurses. This included notification of a grade 2 pressure ulcer and a high risk of pressure ulcers in the future. Professor Shannon had three significant risk factors. He was immobile, he had diabetes, and he had already suffered a pressure ulcer. The UCH nurses expected the district nurses to check the skin integrity every day. The district nurses did not intend to include this in their daily tasks when they attended the home to assist with insulin administration for diabetic control and with catheter care. If the district nurses had been invited and had attended the UCH discharge planning meeting, this misunderstanding could easily have been identified and the true position understood by all.
3. The district nurses expected the carers employed by Kapital Care UK Limited (the Kapital carers) and commissioned by social services at the City of Westminster Council (social services) to check the skin integrity every day. However, there is no record that they issued such an instruction. Even if individual district nurses had sought to issue such an instruction to Kapital carers, the district nurses only attended the home once a day and did not always
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meet the carers. When the nurses did meet the carers, they rarely saw the same carer twice. 4 Individual district nurses could not ensure that such an instruction was issued to all carers who attended Professor Shannon. This instruction had to be given at a higher level and passed on to each and every Kapital carer.
4. Upon discharge, a Discharge to Assess form was completed by therapists (I am unclear whether occupational or physiotherapists) at UCH and sent to social services at the City of Westminster. The form raised a number of concerns, but did not specifically instruct that carers should check skin integrity every day. That was an omission.
5. The City of Westminster social worker considering the Discharge to Assess form did not consider any part of the form other than the specific instructions. She did not include in her thinking the record a little further down the same page that Professor Shannon had a grade 2 pressure ulcer and was at high risk of developing pressure ulcers. She told me that she was a social worker and not medically trained to read the Discharge to Assess form. However, she accepted that the form clearly stated that Professor Shannon had a grade 2 pressure ulcer and was at high risk of pressure ulcers. She said that she did not issue a specific instruction to Kapital to check skin integrity every day.
6. When a district nurse arrived at the home the morning after discharge, she found that Professor Shannon’s catheter bag was so full it had become detached, and he had demonstrably and significantly soiled himself. He had been in this condition when a Kapital carer had visited earlier that same morning, but the carer had not cleaned him or changed the catheter bag. It took the district nurse three hours properly to take care of her patient’s needs. Carers from Kapital had been booked to visit Professor Shannon’s home for an hour four times each day by the City of Westminster. One of their specific tasks was to attend to the personal hygiene needs of this elderly and vulnerable man who was unable to attend to them himself. The Kapital carer’s explanation for leaving him in this condition was that there was no soap or towel in the property. This excuse struck me as demonstrating an appalling lack of humanity and I was shocked to hear of it. 5 In fact, Professor Shannon was obviously dearly loved, and his friends had done everything they could do to make his home ready for him, including stocking his bathroom with soap and towels readily found by the district nurse. Apparently, the Kapital carer had simply not opened the bathroom cupboard.
7. The City of Westminster undertook a safeguarding investigation after Professor Shannon’s death. In that investigation, intended to learn lessons for the benefit of others, the City of Westminster investigator accepted, as the social worker had at the time, the explanation given by Kapital that the towels had been brought to the property after the carer’s first visit that morning and therefore had not been available to the carer. The investigator did not interview the Kapital carer. He accepted at inquest that he should have done. There was no evidence to support Kapital’s assertion and it was in fact completely inaccurate.
8. The safeguarding investigation was concluded by the social worker from Westminster at the end of June 2022, but I was told that there have been no changes made to systems or training in the intervening five months. The social worker has recently emailed partner agencies suggesting a meeting, but no such meeting has taken place. Apparently, no lessons have been learnt.
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9. What struck me most forcibly throughout the inquest touching the death of Richard Shannon, was that lots of professionals were charged with his care, lots of professionals attended his home, lots of professional met him, yet still very basic elements of his needs were omitted. Despite all the resources expended, he was not cared for as a whole person. In 2022, we must be able to expect better for those in need. 6 Action taken/timescale A number of actions were taken including linking with borough partners. UCLH actions relate to concerns 1, 2, 4 and 9 and are detailed below;
1. The discharge team at University College Hospital (UCH) did not seek a pressure relieving bed and mattress to replace Professor Shannon’s own before he was discharged on 5 January. Actions:
• The Tissue Viability (TV) team at UCLH now document their reviews on the discharge planning section of the patient’s electronic health record system (Epic). This was previously completed under another section of the patient notes. This change ensures that the discharge team has a holistic view of the patient’s need, including skin concerns / risks and requests for equipment/dressings/skin checks, prior to discharge. This in turn ensures improved communication of risk, from UCLH discharge team to our community and social care partners.
• Registered nurses will be trained to add nursing notes (pertinent to discharge and continuity of care), on the discharge summaries on Epic . This has been completed for the senior staff nurses working in the ward (care of older people), where Professor Shannon was a patient. This training has been evaluated and will now be rolled out to specific wards across all hospital sites that link with community and social care partners. This will be review quarterly and reported quarterly through the Harm-free Care Committee and the Nursing and Midwifery Board (chaired by the Chief Nurse). The Trust Patient Safety Committee (PSC) will also be updated on a quarterly basis.
• North Central London (NCL) Integrated Care Board (ICB) has developed a NCL tissue viability passport which is designed to be a consistent tool for recording and communicating information about pressure ulcers at the point of discharge and within the community. UCLH discharge and tissue viability teams have contributed to the development of the tool. The tissue viability passport form will be used across NCL hospitals, when signed off by the NCL ICB senior management team. Once finalised, this form will be embedded into the UCLH’s Epic system for hospital use.
• UCLH has liaised with Central London Community Health (CLCH) to improve links with district nurses. The UCLH discharge team now has the phone number of the district nurses and know that between 2-4pm Monday-Friday, the team will be available to discuss any discharges.
• We have set up monthly review meetings with CLCH to ensure the partnership working continues to develop and improve including, enhancing UCLH’s understanding of the district nurse role. This will also include joint education and training, to better understand roles and responsibilities and reduce silo working and gaps in care.
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• The district nurses have agreed that they will attend meetings with UCLH for any complex patient discharges.
• Westminster City Council has agreed to base a social worker in UCLH to improve communication and joint working across health and social care. This started on 23rd January 2023
• Following discussion with the Islington Transfer of Care Hub Clinical Screener, all referrals should be screened to ensure that the skin section and all nursing sections are completed by the therapist/referrer, prior to them being sent to the community partners. This is the expected process which will be further communicated to staff to ensure clinical information is highlighted and an appropriate care plan identified.
2. Upon discharge, UCLH sent a referral to the district nurses. This included notification of a grade 2 pressure ulcer and a high risk of pressure ulcers in the future. The UCH nurses expected the district nurses to check the skin integrity every day. The district nurses did not intend to include this in their daily tasks when they attended the home to assist with insulin administration for diabetic control and with catheter care. Actions:
• UCLH has liaised with Central London Community Health (CLCH) to improve links with district nurses. The UCLH discharge team now has the phone number of the district nurses and know that between 2-4pm Monday-Friday the team will be available to discuss any discharges.
• We have set up monthly review meetings with CLCH to ensure the partnership working continues to develop and improve including enhancing UCLH’s understanding of the District Nurse role.
• The district nurses have agreed that they will attend meetings with UCLH for any complex discharges.
4. Upon discharge, a Discharge to Assess form was completed by therapists at UCLH and sent to social services at the City of Westminster. The form raised a number of concerns, but did not specifically instruct that carers should check skin integrity every day. That was an omission. Actions:
• Pressure ulcer training for therapists has commenced in the ward where Professor Shannon was a patient. This includes understanding of the causes and risk factors for pressure ulcers to ensure information/instructions in relation to skin care and risk is communicated clearly on the discharge to assess forms. Regular drop-in teaching sessions continue, as well as planned sessions to ensure all therapists in the trust have had this training by the end of June 2023. This training will be evaluated and reported via the Harm-free Care Committee and the Nursing and Midwifery Board (chaired by the Chief Nurse).
9. What struck me most forcibly throughout the inquest touching the death of Richard Shannon, was that lots of professionals were charged with his care, lots of professionals
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att e n d e d hi s h o m e, l ot s of pr of e s si o n al m et hi m, y et still v er y b a si c el e m e nt s of hi s n e e d s w er e o mitt e d. D e s pit e all t h e r e s o ur c e s e x p e n d e d, h e w a s n ot c ar e d f or a s a w h ol e p er s o n. I n 2 0 2 2, w e m u st b e a bl e t o e x p e ct b ett er f or t h o s e i n n e e d. A cti o n s: W e h a v e r e vi e w e d a n d i m pr o v e d o ur l o c al pr o c e s s e s a n d e d u c ati o n f or st aff t o pr e v e nt f urt h er p o or o ut c o m e s f or p ati e nt s. T hi s i s si g nifi c a ntl y str e n gt h e n e d b y w or ki n g c oll a b or ati v el y wit h o ur p art n er s i n t h e c o m m u nit y a n d s o ci al c ar e. W e ar e c o nfi d e nt t hi s i m pr o v e d a p pr o a c h will e n h a n c e t h e q u alit y a n d s af et y of t h e h o s pit al di s c h ar g e pr o c e s s a n d c ar e o ut si d e of h o s pit al . W e ar e c o nfi d e nt t h at w e h a v e a d dr e s s e d t h e c o n c er n s r ai s e d t o e n s ur e t h e c ar e w e pr o vi d e t o p ati e nt s i s s af e a n d h oli sti c . T o a s s ur e o ur s el v e s a n d ot h er s , w e h a v e a gr e e d t o m e et m o nt hl y a s a n e wl y f or m e d p ar t n er s hi p t o r e vi e w pr o gr e s s a g ai n st t h e s e a cti o n s, s h ar e l e ar ni n g a n d c oll a b or at e o n i m pr o v e m e nt s.
7 T hi s r e s p o n s e h a s b e e n pr e p ar e d b y D e p ut y C hi ef N ur s e 8 D at e of r e s p o n s e 2 4 t h J a n u ar y 2 0 2 3
Y o ur s si n c er el y ,
C hi ef N ur s e ( A cti n g)
c c: C at h y M o o n e y, Dir e ct or f or Q u alit y a n d S af et y, U C L H
K at h ari n e K a n d el a ki, Cl ai m s & I n q u e st s M a n a g er, U C L H
Action Taken
Westminster City Council has worked with partner agencies to review integrated discharge, and multidisciplinary discharge meetings are held pre-discharge including the attendance of a District Nurse and social worker. The contract specifications for commissioned services will have an enhanced focus on the delivery of person-centred care. (AI summary)
Westminster City Council has worked with partner agencies to review integrated discharge, and multidisciplinary discharge meetings are held pre-discharge including the attendance of a District Nurse and social worker. The contract specifications for commissioned services will have an enhanced focus on the delivery of person-centred care. (AI summary)
View full response
Dear Madam I write on behalf of Westminster City Council (“the local authority”). This is a response to the Regulation 28 report dated 5 December 2022 regarding the death of Professor Richard Shannon on 19 February 2022. The local authority and partner agencies referred to in your report have been working together in an integrated way across the organisations involved in Professor Shannon’s care to provide a thorough response covering all nine areas of concern raised in your report, as relevant across the agencies. The other agencies will be providing their own responses to you but all actions to be taken between us have been coordinated and agreed so that there are no omissions. Several changes to practice and procedure have already taken place since the safeguarding enquiry outcome meeting on 16 June 2022 and we are each committed to continuing to implement the learning and improvements highlighted. This includes both within our individual organisations and between our organisations to improve the co-ordination and communication of care arrangements for our residents and patients which is of paramount importance to us. The following table provides you with the local authority’s response to each of the concerns identified, any actions already considered and taken and those in progress. Regulation 28: Matters of Concern Actioned by the Local Authority Concern 1: The discharge team at University College Hospital (UCH) did not seek a pressure relieving bed and mattress to replace Professor Shannon’s own before he was discharged on 5 January. The authority is committed to supporting an integrated hospital discharge process and will ensure social workers are core members of hospital multi-disciplinary discharge planning meetings.
Concern 2: If the district nurses had been invited and had attended the UCH discharge planning meeting, We welcome the participation of District Nurses at discharge meetings, which will ensure that holistic clinical input is included in plans for the benefit of everybody providing care and support.
this misunderstanding could easily have been identified and the true position understood by all.
Concern 3: The district nurses expected the carers employed by Kapital Care UK Limited (the Kapital carers) and commissioned by social services at the City of Westminster Council (social services) to check the skin integrity every day. However, there is no record that they issued such an instruction. Local Authority Action:
• To support an all-agency approach to discharge planning, social workers now use a checklist to ensure that all aspects of the care plan have been actioned prior to discharge, e.g., equipment delivery, district nurse involvement, care agency fully briefed. This is to minimise the risk of there being any gaps in the discharge process across all agencies.
Concern 4 The form (DTA) raised a number of concerns but did not specifically instruct that carers should check skin integrity every day. That was an omission.
Local Authority Action:
• The local authority has introduced a new Hospital Discharge Reablement Assessment Form. Implementation has begun and will be fully embedded by 6th February 2023. The new form includes prompts and mandatory fields in medical areas such as pressure care, manual handling, and medication. This information is transferred to the care plan sent to care agencies delivering social care. This tool is in operational use locally and is required to be shared across agencies.
• To support implementation of the new form and embed new practice for discharge, workshops were held in December 2022 and January 2023 with UCH discharge staff, CLCH and Central North West London NHS Foundation Trust (CNWL) community NHS staff with Adult Social Care.
Concerns 5: The City of Westminster social worker considering the Discharge to Assess form did not include in her thinking that Professor Shannon had a grade 2 pressure ulcer and was at high risk of developing pressure ulcers
Local Authority Action:
• Since December 2022 the local authority has arranged and facilitated three social care hospital practice workshops with the staff teams to raise awareness and improve practice. The workshops focused on the key points raised by the coroner at the end of the Inquest with regards to the social workers’ understanding of their role in both co-ordinating the care for discharge and information that is shared and communicated with care agencies.
• Standard operating procedures are being updated to reflect the outcomes of the workshops. This includes: o a training package for newly qualified social workers entering the service and for experienced social workers as part of their yearly appraisal and continuous professional development. The training package focuses on identifying care needs associated with pressure care, manual handling and equipment, medication, risk management plans and the co-ordination role of a social worker. o an improved tool for discharge including a template checklist to ensure all key areas are addressed. o key escalation points and links with community providers including District Nurses.
Concern 6: When the District Nurse visited Professor Shannon the day after his discharge, his catheter bag was so full it had come detached, and he was demonstrably soiled. Local Authority Action:
• The local authority has worked with Kapital Care to support improvements in their practice, as detailed in Kapital Care’s response regarding their training, documentation, escalation to us if there is an issue, improved communication with District Nurses and others involved in a person’s care.
• Local authority contract managers have been meeting regularly with Kapital Care and will continue to monitor delivery of their agreed actions quarterly. Concern 7. The City of Westminster undertook a safeguarding investigation after Professor Shannon’s death. In that investigation, intended to learn lessons for the benefit of others, the City of Westminster investigator accepted, as the social worker had at the time, the explanation given by Kapital that the towels had been brought to the property after the carer’s first visit that morning and therefore had not been available to the carer. The investigator did not interview the Kapital carer. He accepted at inquest that he should have done. There was no evidence to support Kapital’s assertion and it was in fact completely inaccurate.
Local Authority Action
• In any safeguarding enquiry, there is a judgement to be made as to whether to speak directly to every individual involved, or whether to delegate some of those conversations to others. In this case, the Safeguarding Adults Manager made the decision to delegate the conversation with the Kapital care worker to the care worker’s line manager. On reflection this was a conflict of interest.
• The Safeguarding Service has revised its practice so that when reviewing cases in professional supervision, it will explore whether delegated or direct conversations should take place, factoring in whether there are conflicts of interest in individual agencies being asked to conduct parts of the safeguarding enquiry.
Concern 8. The safeguarding investigation was concluded by the social worker from Westminster at the end of June 2022, but I was told that there have been no changes made to systems or training in the intervening five months. The social worker has recently emailed partner agencies suggesting a meeting, but no such meeting has taken place. Apparently, no lessons have been learnt Local Authority Action
• A referral for a Section 44 Safeguarding Adults Review by the Safeguarding Adults Board in relation to Professor Shannon was made on 6 December 2022. This multi-agency review process will seek to determine what relevant agencies and individuals involved could have done differently in this case and promote effective learning outcomes and improvements for the future for all involved organisations.
• The London Multi-Agency Safeguarding Adults Policy requires all individual organisations to review the recommendations identified in the Section 42 Safeguarding Enquiry investigation report for any lessons to be learned. This has now taken place, but the delay is acknowledged and is a learning that will be addressed by all partners.
Concern 9: What struck me most forcibly throughout the inquest touching the death of Richard Shannon, was that The local authority has worked with partner agencies to review and enhance our collective approach to integrated discharge, ensuring more robust co-ordination by professionals of a patient’s complete care needs.
lots of professionals were charged with his care, lots of professionals attended his home, lots of professional met him, yet still very basic elements of his needs were omitted. Despite all the resources expended, he was not cared for as a whole person.
Local Authority Action:
• Multidisciplinary discharge meetings are held pre-discharge including the attendance of a District Nurse and social worker. The hospital discharge social worker ensures this planning forms the detailed care plans for domiciliary care services to follow.
• The local authority’s contract specifications for commissioned services will have an enhanced focus on the delivery of person-centred care.
The authority is addressing the multiple actions required to improve hospital discharge and delivery of co-ordinated care. All future actions and learning arising from Professor Shannon’s death will be implemented with whole person care central to any changes. We are absolutely committed to maintaining and embedding those improvements already implemented, prioritising implementation of those in progress and consistently reviewing our practice. The local authority will continue working with partner agencies to build on the current improvements, which will be further informed by the outcome of the current Safeguarding Adults Review process.
Concern 2: If the district nurses had been invited and had attended the UCH discharge planning meeting, We welcome the participation of District Nurses at discharge meetings, which will ensure that holistic clinical input is included in plans for the benefit of everybody providing care and support.
this misunderstanding could easily have been identified and the true position understood by all.
Concern 3: The district nurses expected the carers employed by Kapital Care UK Limited (the Kapital carers) and commissioned by social services at the City of Westminster Council (social services) to check the skin integrity every day. However, there is no record that they issued such an instruction. Local Authority Action:
• To support an all-agency approach to discharge planning, social workers now use a checklist to ensure that all aspects of the care plan have been actioned prior to discharge, e.g., equipment delivery, district nurse involvement, care agency fully briefed. This is to minimise the risk of there being any gaps in the discharge process across all agencies.
Concern 4 The form (DTA) raised a number of concerns but did not specifically instruct that carers should check skin integrity every day. That was an omission.
Local Authority Action:
• The local authority has introduced a new Hospital Discharge Reablement Assessment Form. Implementation has begun and will be fully embedded by 6th February 2023. The new form includes prompts and mandatory fields in medical areas such as pressure care, manual handling, and medication. This information is transferred to the care plan sent to care agencies delivering social care. This tool is in operational use locally and is required to be shared across agencies.
• To support implementation of the new form and embed new practice for discharge, workshops were held in December 2022 and January 2023 with UCH discharge staff, CLCH and Central North West London NHS Foundation Trust (CNWL) community NHS staff with Adult Social Care.
Concerns 5: The City of Westminster social worker considering the Discharge to Assess form did not include in her thinking that Professor Shannon had a grade 2 pressure ulcer and was at high risk of developing pressure ulcers
Local Authority Action:
• Since December 2022 the local authority has arranged and facilitated three social care hospital practice workshops with the staff teams to raise awareness and improve practice. The workshops focused on the key points raised by the coroner at the end of the Inquest with regards to the social workers’ understanding of their role in both co-ordinating the care for discharge and information that is shared and communicated with care agencies.
• Standard operating procedures are being updated to reflect the outcomes of the workshops. This includes: o a training package for newly qualified social workers entering the service and for experienced social workers as part of their yearly appraisal and continuous professional development. The training package focuses on identifying care needs associated with pressure care, manual handling and equipment, medication, risk management plans and the co-ordination role of a social worker. o an improved tool for discharge including a template checklist to ensure all key areas are addressed. o key escalation points and links with community providers including District Nurses.
Concern 6: When the District Nurse visited Professor Shannon the day after his discharge, his catheter bag was so full it had come detached, and he was demonstrably soiled. Local Authority Action:
• The local authority has worked with Kapital Care to support improvements in their practice, as detailed in Kapital Care’s response regarding their training, documentation, escalation to us if there is an issue, improved communication with District Nurses and others involved in a person’s care.
• Local authority contract managers have been meeting regularly with Kapital Care and will continue to monitor delivery of their agreed actions quarterly. Concern 7. The City of Westminster undertook a safeguarding investigation after Professor Shannon’s death. In that investigation, intended to learn lessons for the benefit of others, the City of Westminster investigator accepted, as the social worker had at the time, the explanation given by Kapital that the towels had been brought to the property after the carer’s first visit that morning and therefore had not been available to the carer. The investigator did not interview the Kapital carer. He accepted at inquest that he should have done. There was no evidence to support Kapital’s assertion and it was in fact completely inaccurate.
Local Authority Action
• In any safeguarding enquiry, there is a judgement to be made as to whether to speak directly to every individual involved, or whether to delegate some of those conversations to others. In this case, the Safeguarding Adults Manager made the decision to delegate the conversation with the Kapital care worker to the care worker’s line manager. On reflection this was a conflict of interest.
• The Safeguarding Service has revised its practice so that when reviewing cases in professional supervision, it will explore whether delegated or direct conversations should take place, factoring in whether there are conflicts of interest in individual agencies being asked to conduct parts of the safeguarding enquiry.
Concern 8. The safeguarding investigation was concluded by the social worker from Westminster at the end of June 2022, but I was told that there have been no changes made to systems or training in the intervening five months. The social worker has recently emailed partner agencies suggesting a meeting, but no such meeting has taken place. Apparently, no lessons have been learnt Local Authority Action
• A referral for a Section 44 Safeguarding Adults Review by the Safeguarding Adults Board in relation to Professor Shannon was made on 6 December 2022. This multi-agency review process will seek to determine what relevant agencies and individuals involved could have done differently in this case and promote effective learning outcomes and improvements for the future for all involved organisations.
• The London Multi-Agency Safeguarding Adults Policy requires all individual organisations to review the recommendations identified in the Section 42 Safeguarding Enquiry investigation report for any lessons to be learned. This has now taken place, but the delay is acknowledged and is a learning that will be addressed by all partners.
Concern 9: What struck me most forcibly throughout the inquest touching the death of Richard Shannon, was that The local authority has worked with partner agencies to review and enhance our collective approach to integrated discharge, ensuring more robust co-ordination by professionals of a patient’s complete care needs.
lots of professionals were charged with his care, lots of professionals attended his home, lots of professional met him, yet still very basic elements of his needs were omitted. Despite all the resources expended, he was not cared for as a whole person.
Local Authority Action:
• Multidisciplinary discharge meetings are held pre-discharge including the attendance of a District Nurse and social worker. The hospital discharge social worker ensures this planning forms the detailed care plans for domiciliary care services to follow.
• The local authority’s contract specifications for commissioned services will have an enhanced focus on the delivery of person-centred care.
The authority is addressing the multiple actions required to improve hospital discharge and delivery of co-ordinated care. All future actions and learning arising from Professor Shannon’s death will be implemented with whole person care central to any changes. We are absolutely committed to maintaining and embedding those improvements already implemented, prioritising implementation of those in progress and consistently reviewing our practice. The local authority will continue working with partner agencies to build on the current improvements, which will be further informed by the outcome of the current Safeguarding Adults Review process.
Action Taken
UCLH has reviewed and improved local processes and education for staff to prevent further poor outcomes for patients. Pressure ulcer training for therapists has commenced, with completion planned by the end of June 2023 and they have agreed to meet monthly as a newly formed partnership to review progress against the actions, share learning and collaborate on improvements. (AI summary)
UCLH has reviewed and improved local processes and education for staff to prevent further poor outcomes for patients. Pressure ulcer training for therapists has commenced, with completion planned by the end of June 2023 and they have agreed to meet monthly as a newly formed partnership to review progress against the actions, share learning and collaborate on improvements. (AI summary)
View full response
Dear Ma’am, Re: Mr Richard Shannon Prevention of Future Death report We write to provide you with a detailed response to the Regulation 28 report dated 5th December 2022, regarding the death of Professor Richard Shannon on 19th February
2022. We have worked together, in an integrated way, across the organisations involved in Professor Shannon’s care, to provide a thorough response covering all nine areas of concern raised in your report, as relevant across the agencies. Several changes to practice and procedure have already taken place since the safeguarding enquiry outcome meeting on 3rd February 2022. We are each committed to continuing to implement the learning and improvements highlighted. This includes both within our individual organisations, and between our organisations, to improve the co-ordination and communication of care arrangements for our residents and patients which is of paramount importance to us.
1 This response is made on behalf of Acting Chief Nurse, University College London Hospitals NHS Foundation Trust 2 Regulation 28 Report This response follows a report by Coroner ME Hassell on 5th December 2022 3 Investigation and inquest On 11 March 2022, I commenced an investigation into the death of Richard Thomas Shannon aged 91 years. The investigation concluded at the end of the inquest on 24 November 2022. I made a narrative determination at inquest as follows. “Professor Shannon died as a consequence of an extremely severe pressure ulcer. This developed at some point between his discharge from hospital on 5 January and his readmission on 13 January 2022, in all likelihood between 10 and 13 January. Whilst a pressure ulcer for a person with his co-morbidities (most particularly immobility and diabetes) is a natural cause of death, there was a failure properly to monitor his skin integrity in his final days.
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If his skin integrity had been properly monitored and he had been appropriately treated, he would not have developed a pressure sore of that severity and would not have died.” The medical cause of death was: 1a pneumonia 1b coccyx osteomyelitis 1c infected sacral pressure ulcer 2 type II diabetes mellitus, previous stroke and previous throat cancer 4 Circumstances of the death When Professor Shannon was discharged from University College London Hospital on 5 January 2022, his sacral pressure ulcer was almost completely healed. When he was readmitted on 13 January 2022, his condition was irretrievable. His sacral pressure ulcer was now 5-6cms in diameter, covered in black, necrotic tissue, and unstageable. The infection that penetrated to the bone killed him. 5 Coroner's concerns The MATTERS OF CONCERN are as follows.
1. The discharge team at University College Hospital (UCH) did not seek a pressure relieving bed and mattress to replace Professor Shannon’s own before he was discharged on 5 January. This was because his sacral pressure ulcer was almost fully healed and so they did not consider it necessary. However, he was at risk of further pressure ulcers and so it was a measure that should have been sought. The changing of a bed is more difficult to organise once the patient is home and sleeping in it. If the Central London Community Healthcare district nursing team at Soho Centre for Health and Care (the district nurses) had been invited and had attended the UCH discharge planning meeting, it is much more likely that this measure would have been considered.
2. Upon discharge, UCH sent a referral to the district nurses. This included notification of a grade 2 pressure ulcer and a high risk of pressure ulcers in the future. Professor Shannon had three significant risk factors. He was immobile, he had diabetes, and he had already suffered a pressure ulcer. The UCH nurses expected the district nurses to check the skin integrity every day. The district nurses did not intend to include this in their daily tasks when they attended the home to assist with insulin administration for diabetic control and with catheter care. If the district nurses had been invited and had attended the UCH discharge planning meeting, this misunderstanding could easily have been identified and the true position understood by all.
3. The district nurses expected the carers employed by Kapital Care UK Limited (the Kapital carers) and commissioned by social services at the City of Westminster Council (social services) to check the skin integrity every day. However, there is no record that they issued such an instruction. Even if individual district nurses had sought to issue such an instruction to Kapital carers, the district nurses only attended the home once a day and did not always
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meet the carers. When the nurses did meet the carers, they rarely saw the same carer twice. 4 Individual district nurses could not ensure that such an instruction was issued to all carers who attended Professor Shannon. This instruction had to be given at a higher level and passed on to each and every Kapital carer.
4. Upon discharge, a Discharge to Assess form was completed by therapists (I am unclear whether occupational or physiotherapists) at UCH and sent to social services at the City of Westminster. The form raised a number of concerns, but did not specifically instruct that carers should check skin integrity every day. That was an omission.
5. The City of Westminster social worker considering the Discharge to Assess form did not consider any part of the form other than the specific instructions. She did not include in her thinking the record a little further down the same page that Professor Shannon had a grade 2 pressure ulcer and was at high risk of developing pressure ulcers. She told me that she was a social worker and not medically trained to read the Discharge to Assess form. However, she accepted that the form clearly stated that Professor Shannon had a grade 2 pressure ulcer and was at high risk of pressure ulcers. She said that she did not issue a specific instruction to Kapital to check skin integrity every day.
6. When a district nurse arrived at the home the morning after discharge, she found that Professor Shannon’s catheter bag was so full it had become detached, and he had demonstrably and significantly soiled himself. He had been in this condition when a Kapital carer had visited earlier that same morning, but the carer had not cleaned him or changed the catheter bag. It took the district nurse three hours properly to take care of her patient’s needs. Carers from Kapital had been booked to visit Professor Shannon’s home for an hour four times each day by the City of Westminster. One of their specific tasks was to attend to the personal hygiene needs of this elderly and vulnerable man who was unable to attend to them himself. The Kapital carer’s explanation for leaving him in this condition was that there was no soap or towel in the property. This excuse struck me as demonstrating an appalling lack of humanity and I was shocked to hear of it. 5 In fact, Professor Shannon was obviously dearly loved, and his friends had done everything they could do to make his home ready for him, including stocking his bathroom with soap and towels readily found by the district nurse. Apparently, the Kapital carer had simply not opened the bathroom cupboard.
7. The City of Westminster undertook a safeguarding investigation after Professor Shannon’s death. In that investigation, intended to learn lessons for the benefit of others, the City of Westminster investigator accepted, as the social worker had at the time, the explanation given by Kapital that the towels had been brought to the property after the carer’s first visit that morning and therefore had not been available to the carer. The investigator did not interview the Kapital carer. He accepted at inquest that he should have done. There was no evidence to support Kapital’s assertion and it was in fact completely inaccurate.
8. The safeguarding investigation was concluded by the social worker from Westminster at the end of June 2022, but I was told that there have been no changes made to systems or training in the intervening five months. The social worker has recently emailed partner agencies suggesting a meeting, but no such meeting has taken place. Apparently, no lessons have been learnt.
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9. What struck me most forcibly throughout the inquest touching the death of Richard Shannon, was that lots of professionals were charged with his care, lots of professionals attended his home, lots of professional met him, yet still very basic elements of his needs were omitted. Despite all the resources expended, he was not cared for as a whole person. In 2022, we must be able to expect better for those in need. 6 Action taken/timescale A number of actions were taken including linking with borough partners. UCLH actions relate to concerns 1, 2, 4 and 9 and are detailed below;
1. The discharge team at University College Hospital (UCH) did not seek a pressure relieving bed and mattress to replace Professor Shannon’s own before he was discharged on 5 January. Actions:
• The Tissue Viability (TV) team at UCLH now document their reviews on the discharge planning section of the patient’s electronic health record system (Epic). This was previously completed under another section of the patient notes. This change ensures that the discharge team has a holistic view of the patient’s need, including skin concerns / risks and requests for equipment/dressings/skin checks, prior to discharge. This in turn ensures improved communication of risk, from UCLH discharge team to our community and social care partners.
• Registered nurses will be trained to add nursing notes (pertinent to discharge and continuity of care), on the discharge summaries on Epic . This has been completed for the senior staff nurses working in the ward (care of older people), where Professor Shannon was a patient. This training has been evaluated and will now be rolled out to specific wards across all hospital sites that link with community and social care partners. This will be review quarterly and reported quarterly through the Harm-free Care Committee and the Nursing and Midwifery Board (chaired by the Chief Nurse). The Trust Patient Safety Committee (PSC) will also be updated on a quarterly basis.
• North Central London (NCL) Integrated Care Board (ICB) has developed a NCL tissue viability passport which is designed to be a consistent tool for recording and communicating information about pressure ulcers at the point of discharge and within the community. UCLH discharge and tissue viability teams have contributed to the development of the tool. The tissue viability passport form will be used across NCL hospitals, when signed off by the NCL ICB senior management team. Once finalised, this form will be embedded into the UCLH’s Epic system for hospital use.
• UCLH has liaised with Central London Community Health (CLCH) to improve links with district nurses. The UCLH discharge team now has the phone number of the district nurses and know that between 2-4pm Monday-Friday, the team will be available to discuss any discharges.
• We have set up monthly review meetings with CLCH to ensure the partnership working continues to develop and improve including, enhancing UCLH’s understanding of the district nurse role. This will also include joint education and training, to better understand roles and responsibilities and reduce silo working and gaps in care.
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• The district nurses have agreed that they will attend meetings with UCLH for any complex patient discharges.
• Westminster City Council has agreed to base a social worker in UCLH to improve communication and joint working across health and social care. This started on 23rd January 2023
• Following discussion with the Islington Transfer of Care Hub Clinical Screener, all referrals should be screened to ensure that the skin section and all nursing sections are completed by the therapist/referrer, prior to them being sent to the community partners. This is the expected process which will be further communicated to staff to ensure clinical information is highlighted and an appropriate care plan identified.
2. Upon discharge, UCLH sent a referral to the district nurses. This included notification of a grade 2 pressure ulcer and a high risk of pressure ulcers in the future. The UCH nurses expected the district nurses to check the skin integrity every day. The district nurses did not intend to include this in their daily tasks when they attended the home to assist with insulin administration for diabetic control and with catheter care. Actions:
• UCLH has liaised with Central London Community Health (CLCH) to improve links with district nurses. The UCLH discharge team now has the phone number of the district nurses and know that between 2-4pm Monday-Friday the team will be available to discuss any discharges.
• We have set up monthly review meetings with CLCH to ensure the partnership working continues to develop and improve including enhancing UCLH’s understanding of the District Nurse role.
• The district nurses have agreed that they will attend meetings with UCLH for any complex discharges.
4. Upon discharge, a Discharge to Assess form was completed by therapists at UCLH and sent to social services at the City of Westminster. The form raised a number of concerns, but did not specifically instruct that carers should check skin integrity every day. That was an omission. Actions:
• Pressure ulcer training for therapists has commenced in the ward where Professor Shannon was a patient. This includes understanding of the causes and risk factors for pressure ulcers to ensure information/instructions in relation to skin care and risk is communicated clearly on the discharge to assess forms. Regular drop-in teaching sessions continue, as well as planned sessions to ensure all therapists in the trust have had this training by the end of June 2023. This training will be evaluated and reported via the Harm-free Care Committee and the Nursing and Midwifery Board (chaired by the Chief Nurse).
9. What struck me most forcibly throughout the inquest touching the death of Richard Shannon, was that lots of professionals were charged with his care, lots of professionals
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2022. We have worked together, in an integrated way, across the organisations involved in Professor Shannon’s care, to provide a thorough response covering all nine areas of concern raised in your report, as relevant across the agencies. Several changes to practice and procedure have already taken place since the safeguarding enquiry outcome meeting on 3rd February 2022. We are each committed to continuing to implement the learning and improvements highlighted. This includes both within our individual organisations, and between our organisations, to improve the co-ordination and communication of care arrangements for our residents and patients which is of paramount importance to us.
1 This response is made on behalf of Acting Chief Nurse, University College London Hospitals NHS Foundation Trust 2 Regulation 28 Report This response follows a report by Coroner ME Hassell on 5th December 2022 3 Investigation and inquest On 11 March 2022, I commenced an investigation into the death of Richard Thomas Shannon aged 91 years. The investigation concluded at the end of the inquest on 24 November 2022. I made a narrative determination at inquest as follows. “Professor Shannon died as a consequence of an extremely severe pressure ulcer. This developed at some point between his discharge from hospital on 5 January and his readmission on 13 January 2022, in all likelihood between 10 and 13 January. Whilst a pressure ulcer for a person with his co-morbidities (most particularly immobility and diabetes) is a natural cause of death, there was a failure properly to monitor his skin integrity in his final days.
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If his skin integrity had been properly monitored and he had been appropriately treated, he would not have developed a pressure sore of that severity and would not have died.” The medical cause of death was: 1a pneumonia 1b coccyx osteomyelitis 1c infected sacral pressure ulcer 2 type II diabetes mellitus, previous stroke and previous throat cancer 4 Circumstances of the death When Professor Shannon was discharged from University College London Hospital on 5 January 2022, his sacral pressure ulcer was almost completely healed. When he was readmitted on 13 January 2022, his condition was irretrievable. His sacral pressure ulcer was now 5-6cms in diameter, covered in black, necrotic tissue, and unstageable. The infection that penetrated to the bone killed him. 5 Coroner's concerns The MATTERS OF CONCERN are as follows.
1. The discharge team at University College Hospital (UCH) did not seek a pressure relieving bed and mattress to replace Professor Shannon’s own before he was discharged on 5 January. This was because his sacral pressure ulcer was almost fully healed and so they did not consider it necessary. However, he was at risk of further pressure ulcers and so it was a measure that should have been sought. The changing of a bed is more difficult to organise once the patient is home and sleeping in it. If the Central London Community Healthcare district nursing team at Soho Centre for Health and Care (the district nurses) had been invited and had attended the UCH discharge planning meeting, it is much more likely that this measure would have been considered.
2. Upon discharge, UCH sent a referral to the district nurses. This included notification of a grade 2 pressure ulcer and a high risk of pressure ulcers in the future. Professor Shannon had three significant risk factors. He was immobile, he had diabetes, and he had already suffered a pressure ulcer. The UCH nurses expected the district nurses to check the skin integrity every day. The district nurses did not intend to include this in their daily tasks when they attended the home to assist with insulin administration for diabetic control and with catheter care. If the district nurses had been invited and had attended the UCH discharge planning meeting, this misunderstanding could easily have been identified and the true position understood by all.
3. The district nurses expected the carers employed by Kapital Care UK Limited (the Kapital carers) and commissioned by social services at the City of Westminster Council (social services) to check the skin integrity every day. However, there is no record that they issued such an instruction. Even if individual district nurses had sought to issue such an instruction to Kapital carers, the district nurses only attended the home once a day and did not always
3/6
meet the carers. When the nurses did meet the carers, they rarely saw the same carer twice. 4 Individual district nurses could not ensure that such an instruction was issued to all carers who attended Professor Shannon. This instruction had to be given at a higher level and passed on to each and every Kapital carer.
4. Upon discharge, a Discharge to Assess form was completed by therapists (I am unclear whether occupational or physiotherapists) at UCH and sent to social services at the City of Westminster. The form raised a number of concerns, but did not specifically instruct that carers should check skin integrity every day. That was an omission.
5. The City of Westminster social worker considering the Discharge to Assess form did not consider any part of the form other than the specific instructions. She did not include in her thinking the record a little further down the same page that Professor Shannon had a grade 2 pressure ulcer and was at high risk of developing pressure ulcers. She told me that she was a social worker and not medically trained to read the Discharge to Assess form. However, she accepted that the form clearly stated that Professor Shannon had a grade 2 pressure ulcer and was at high risk of pressure ulcers. She said that she did not issue a specific instruction to Kapital to check skin integrity every day.
6. When a district nurse arrived at the home the morning after discharge, she found that Professor Shannon’s catheter bag was so full it had become detached, and he had demonstrably and significantly soiled himself. He had been in this condition when a Kapital carer had visited earlier that same morning, but the carer had not cleaned him or changed the catheter bag. It took the district nurse three hours properly to take care of her patient’s needs. Carers from Kapital had been booked to visit Professor Shannon’s home for an hour four times each day by the City of Westminster. One of their specific tasks was to attend to the personal hygiene needs of this elderly and vulnerable man who was unable to attend to them himself. The Kapital carer’s explanation for leaving him in this condition was that there was no soap or towel in the property. This excuse struck me as demonstrating an appalling lack of humanity and I was shocked to hear of it. 5 In fact, Professor Shannon was obviously dearly loved, and his friends had done everything they could do to make his home ready for him, including stocking his bathroom with soap and towels readily found by the district nurse. Apparently, the Kapital carer had simply not opened the bathroom cupboard.
7. The City of Westminster undertook a safeguarding investigation after Professor Shannon’s death. In that investigation, intended to learn lessons for the benefit of others, the City of Westminster investigator accepted, as the social worker had at the time, the explanation given by Kapital that the towels had been brought to the property after the carer’s first visit that morning and therefore had not been available to the carer. The investigator did not interview the Kapital carer. He accepted at inquest that he should have done. There was no evidence to support Kapital’s assertion and it was in fact completely inaccurate.
8. The safeguarding investigation was concluded by the social worker from Westminster at the end of June 2022, but I was told that there have been no changes made to systems or training in the intervening five months. The social worker has recently emailed partner agencies suggesting a meeting, but no such meeting has taken place. Apparently, no lessons have been learnt.
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9. What struck me most forcibly throughout the inquest touching the death of Richard Shannon, was that lots of professionals were charged with his care, lots of professionals attended his home, lots of professional met him, yet still very basic elements of his needs were omitted. Despite all the resources expended, he was not cared for as a whole person. In 2022, we must be able to expect better for those in need. 6 Action taken/timescale A number of actions were taken including linking with borough partners. UCLH actions relate to concerns 1, 2, 4 and 9 and are detailed below;
1. The discharge team at University College Hospital (UCH) did not seek a pressure relieving bed and mattress to replace Professor Shannon’s own before he was discharged on 5 January. Actions:
• The Tissue Viability (TV) team at UCLH now document their reviews on the discharge planning section of the patient’s electronic health record system (Epic). This was previously completed under another section of the patient notes. This change ensures that the discharge team has a holistic view of the patient’s need, including skin concerns / risks and requests for equipment/dressings/skin checks, prior to discharge. This in turn ensures improved communication of risk, from UCLH discharge team to our community and social care partners.
• Registered nurses will be trained to add nursing notes (pertinent to discharge and continuity of care), on the discharge summaries on Epic . This has been completed for the senior staff nurses working in the ward (care of older people), where Professor Shannon was a patient. This training has been evaluated and will now be rolled out to specific wards across all hospital sites that link with community and social care partners. This will be review quarterly and reported quarterly through the Harm-free Care Committee and the Nursing and Midwifery Board (chaired by the Chief Nurse). The Trust Patient Safety Committee (PSC) will also be updated on a quarterly basis.
• North Central London (NCL) Integrated Care Board (ICB) has developed a NCL tissue viability passport which is designed to be a consistent tool for recording and communicating information about pressure ulcers at the point of discharge and within the community. UCLH discharge and tissue viability teams have contributed to the development of the tool. The tissue viability passport form will be used across NCL hospitals, when signed off by the NCL ICB senior management team. Once finalised, this form will be embedded into the UCLH’s Epic system for hospital use.
• UCLH has liaised with Central London Community Health (CLCH) to improve links with district nurses. The UCLH discharge team now has the phone number of the district nurses and know that between 2-4pm Monday-Friday, the team will be available to discuss any discharges.
• We have set up monthly review meetings with CLCH to ensure the partnership working continues to develop and improve including, enhancing UCLH’s understanding of the district nurse role. This will also include joint education and training, to better understand roles and responsibilities and reduce silo working and gaps in care.
5/6
• The district nurses have agreed that they will attend meetings with UCLH for any complex patient discharges.
• Westminster City Council has agreed to base a social worker in UCLH to improve communication and joint working across health and social care. This started on 23rd January 2023
• Following discussion with the Islington Transfer of Care Hub Clinical Screener, all referrals should be screened to ensure that the skin section and all nursing sections are completed by the therapist/referrer, prior to them being sent to the community partners. This is the expected process which will be further communicated to staff to ensure clinical information is highlighted and an appropriate care plan identified.
2. Upon discharge, UCLH sent a referral to the district nurses. This included notification of a grade 2 pressure ulcer and a high risk of pressure ulcers in the future. The UCH nurses expected the district nurses to check the skin integrity every day. The district nurses did not intend to include this in their daily tasks when they attended the home to assist with insulin administration for diabetic control and with catheter care. Actions:
• UCLH has liaised with Central London Community Health (CLCH) to improve links with district nurses. The UCLH discharge team now has the phone number of the district nurses and know that between 2-4pm Monday-Friday the team will be available to discuss any discharges.
• We have set up monthly review meetings with CLCH to ensure the partnership working continues to develop and improve including enhancing UCLH’s understanding of the District Nurse role.
• The district nurses have agreed that they will attend meetings with UCLH for any complex discharges.
4. Upon discharge, a Discharge to Assess form was completed by therapists at UCLH and sent to social services at the City of Westminster. The form raised a number of concerns, but did not specifically instruct that carers should check skin integrity every day. That was an omission. Actions:
• Pressure ulcer training for therapists has commenced in the ward where Professor Shannon was a patient. This includes understanding of the causes and risk factors for pressure ulcers to ensure information/instructions in relation to skin care and risk is communicated clearly on the discharge to assess forms. Regular drop-in teaching sessions continue, as well as planned sessions to ensure all therapists in the trust have had this training by the end of June 2023. This training will be evaluated and reported via the Harm-free Care Committee and the Nursing and Midwifery Board (chaired by the Chief Nurse).
9. What struck me most forcibly throughout the inquest touching the death of Richard Shannon, was that lots of professionals were charged with his care, lots of professionals
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56-Day Deadline
30 Jan 2023
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 11 March 2022, I commenced an investigation into the death of Richard Thomas Shannon aged 91 years. The investigation concluded at the end of the inquest on 24 November 2022. I made a narrative determination at inquest as follows.
“Professor Shannon died as a consequence of an extremely severe pressure ulcer. This developed at some point between his discharge from hospital on 5 January and his readmission on 13 January 2022, in all likelihood between 10 and 13 January.
Whilst a pressure ulcer for a person with his co-morbidities (most particularly immobility and diabetes) is a natural cause of death, there was a failure properly to monitor his skin integrity in his final days.
If his skin integrity had been properly monitored and he had been appropriately treated, he would not have developed a pressure sore of that severity and would not have died.”
The medical cause of death was: 1a pneumonia 1b coccyx osteomyelitis 1c infected sacral pressure ulcer type II diabetes mellitus, previous stroke and previous throat cancer
“Professor Shannon died as a consequence of an extremely severe pressure ulcer. This developed at some point between his discharge from hospital on 5 January and his readmission on 13 January 2022, in all likelihood between 10 and 13 January.
Whilst a pressure ulcer for a person with his co-morbidities (most particularly immobility and diabetes) is a natural cause of death, there was a failure properly to monitor his skin integrity in his final days.
If his skin integrity had been properly monitored and he had been appropriately treated, he would not have developed a pressure sore of that severity and would not have died.”
The medical cause of death was: 1a pneumonia 1b coccyx osteomyelitis 1c infected sacral pressure ulcer type II diabetes mellitus, previous stroke and previous throat cancer
Circumstances of the Death
When Professor Shannon was discharged from University College London Hospital on 5 January 2022, his sacral pressure ulcer was almost completely healed.
When he was readmitted on 13 January 2022, his condition was irretrievable. His sacral pressure ulcer was now 5-6cms in diameter, covered in black, necrotic tissue, and unstageable. The infection that penetrated to the bone killed him.
When he was readmitted on 13 January 2022, his condition was irretrievable. His sacral pressure ulcer was now 5-6cms in diameter, covered in black, necrotic tissue, and unstageable. The infection that penetrated to the bone killed him.
Copies Sent To
friend of Professor Shannon
friend of Professor Shannon
UCH geriatrician
UCH senior staff nurse
, Central London district nurse team leader
, Central London district nurse deputy team leader
, formerly City of Westminster social worker
, City of Westminster social worker & investigator
Care Quality Commission for England
NHS England & NHS Improvement
Professor Chris Whitty, Chief Medical Officer for England
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.