Stephen MAGUIRE
PFD Report
All Responded
Ref: 2021-0138
All 1 response received
· Deadline: 30 Jun 2021
Coroner's Concerns (AI summary)
A personal alarm failed due to not being charged, indicating a flaw in the alarm charging and checking system for staff, which poses a significant risk if alarms are unusable during emergencies.
View full coroner's concerns
1. I heard evidence that the PIT alarm used by staff member, , did not work when pressed. I heard evidence this was alarm was checked after the incident and found to not have been charged. I heard evidence from that Options for Care Limited have a system whereby it is the night staffs’ responsibility to check and charge the PIT alarms overnight, and it is the responsibility of the day care staff to check that their PIT alarms are charged and operational when they come on shift in the morning ("the charging system"). Somehow, this charging system failed. Although not causative in Mr Stephen Anthony MAGUIRE's inquest, if a member of staff is unable to utilise their own PIT alarm in an emergency, this creates an obvious risk of death to both service users and staff alike.
2. I heard evidence that was an agency worker working for Options for Care at the time of Mr Stephen Anthony MAGUIRE's death, and there was a suspicion (but which could not be proven) that they may have either been unaware of the charging system, or made a simple error. Although not causative in Mr Stephen Anthony MAGUIRE's death, if members of staff (both full time and agency workers alike) are unaware of the charging policy, or are not trained and reminded in the same, there is the risk of death if a member of staff is unable to utilise their own PIT alarm in an emergency due to the same not being charged.
2. I heard evidence that was an agency worker working for Options for Care at the time of Mr Stephen Anthony MAGUIRE's death, and there was a suspicion (but which could not be proven) that they may have either been unaware of the charging system, or made a simple error. Although not causative in Mr Stephen Anthony MAGUIRE's death, if members of staff (both full time and agency workers alike) are unaware of the charging policy, or are not trained and reminded in the same, there is the risk of death if a member of staff is unable to utilise their own PIT alarm in an emergency due to the same not being charged.
Responses
Action Taken
Dartmouth House has introduced a 'security lead' role to check PIT alarms at the beginning of each shift and ensure they are working correctly. They will reinforce training through supervision sessions and staff meetings, and agency staff will receive training on PIT alarm use. (AI summary)
Dartmouth House has introduced a 'security lead' role to check PIT alarms at the beginning of each shift and ensure they are working correctly. They will reinforce training through supervision sessions and staff meetings, and agency staff will receive training on PIT alarm use. (AI summary)
View full response
Dear Mr Hodson,
Please see below my response to the regulation 28 report to prevent future deaths received 05 May
2021. This responds to the actions which should be taken identified in the report:
1. Consider how the charging system can be enhanced and strengthened to ensure that staff are provided with properly functioning and charged PIT alarms for their use at the commencement of their shift;
2. Consider how and whether additional training/ refresher training can be provided to staff – both full time and agency alike – to ensure awareness and compliance with the charging system.
Dartmouth House has instituted an operational change with the introduction of a ‘security lead’ role. This is allocated to an appropriately experienced clinical staff member on commencement of each shift.
The security lead is responsible for:
• Checking PIT alarms at the beginning of each shift and ensuring they are working correctly.
• Handing out PIT alarms and keys and recording to whom they have been allocated.
• Identifying any malfunctioning PIT alarms and removing the PIT from circulation and reporting this to a member of the management team or the unit administrator and replacing this with a functioning PIT alarm.
• Ensuring and documenting the return of keys and PIT alarms and placing PIT alarms on charge before handing over to the next security lead.
Options for Care has an existing system of Review and Feedback (supervision) sessions for clinical staff each facilitated by an appropriate line manager. To strengthen existing systems and processes, the management team will utilise these sessions to:
• Share with staff how to report an issue with any PIT alarms to the appropriate party (the management team or unit administrator) to facilitate repair or replacement.
• Explain how to access spare PIT alarms for replacement.
• Explain and reinforce the roles and responsibilities of the allocated security lead role.
• Check staff are aware of how to test a PIT alarm and determine whether it is functioning correctly.
Agency or temporary staff will:
• Receive training on how to effectively test and use the PIT alarms on first attendance at the service.
70 – 72 Handsworth Wood Road Handsworth Wood, Birmingham, B20 2DT
• Receive an update on how to test and use the PIT alarm on each subsequent visit to the service, aided by the security lead for that shift.
These actions and changes will be further reinforced through staff meetings.
I trust these changes already in place at Dartmouth House effectively meet the requirements of the actions which should be taken as identified in the Regulation 28 report. Should you require any further information or clarification, please do not hesitate to contact me.
Please see below my response to the regulation 28 report to prevent future deaths received 05 May
2021. This responds to the actions which should be taken identified in the report:
1. Consider how the charging system can be enhanced and strengthened to ensure that staff are provided with properly functioning and charged PIT alarms for their use at the commencement of their shift;
2. Consider how and whether additional training/ refresher training can be provided to staff – both full time and agency alike – to ensure awareness and compliance with the charging system.
Dartmouth House has instituted an operational change with the introduction of a ‘security lead’ role. This is allocated to an appropriately experienced clinical staff member on commencement of each shift.
The security lead is responsible for:
• Checking PIT alarms at the beginning of each shift and ensuring they are working correctly.
• Handing out PIT alarms and keys and recording to whom they have been allocated.
• Identifying any malfunctioning PIT alarms and removing the PIT from circulation and reporting this to a member of the management team or the unit administrator and replacing this with a functioning PIT alarm.
• Ensuring and documenting the return of keys and PIT alarms and placing PIT alarms on charge before handing over to the next security lead.
Options for Care has an existing system of Review and Feedback (supervision) sessions for clinical staff each facilitated by an appropriate line manager. To strengthen existing systems and processes, the management team will utilise these sessions to:
• Share with staff how to report an issue with any PIT alarms to the appropriate party (the management team or unit administrator) to facilitate repair or replacement.
• Explain how to access spare PIT alarms for replacement.
• Explain and reinforce the roles and responsibilities of the allocated security lead role.
• Check staff are aware of how to test a PIT alarm and determine whether it is functioning correctly.
Agency or temporary staff will:
• Receive training on how to effectively test and use the PIT alarms on first attendance at the service.
70 – 72 Handsworth Wood Road Handsworth Wood, Birmingham, B20 2DT
• Receive an update on how to test and use the PIT alarm on each subsequent visit to the service, aided by the security lead for that shift.
These actions and changes will be further reinforced through staff meetings.
I trust these changes already in place at Dartmouth House effectively meet the requirements of the actions which should be taken as identified in the Regulation 28 report. Should you require any further information or clarification, please do not hesitate to contact me.
Sent To
- Options for Care Ltd
Response Status
Linked responses
1 of 1
56-Day Deadline
30 Jun 2021
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 21 September 2020 I commenced an investigation into the death of Stephen Anthony MAGUIRE. The investigation concluded at the end of the inquest on 27 April 2021 . The conclusion of the inquest was that Mr Stephen Anthony MAGUIRE died due to an accident.
Circumstances of the Death
Mr Stephen Anthony MAGUIRE was detained at Dartmouth House 70-72 Handsworth Wood Road, Handsworth Road, Birmingham (run by Options for Care Limited) pursuant to s.3 Mental Health Act 1983 for treatment of chronic treatment resistant paranoid schizophrenia. At lunchtime on 14/09/2020, Mr Stephen Anthony MAGUIRE was in the lounge area with other residents where he was seen to be about to start eating his lunch, when he got up from the table, walked a short distance and then collapsed. Staff began CPR whilst an ambulance was summoned, and it was noted his chest was not rising with ventilation. He had a difficult anatomy due to a large tongue and adipose neck, and upon examination using laryngoscope, paramedics reported that his airway presented as a Cormack-Lehane grade 4 view. Multiple and repeated efforts were attempted to troubleshoot and clear his airway in accordance with Joint Royal College Ambulance Liaison Committee Guidelines. A period of roughly 30 minutes passed where he was without oxygen before video laryngoscope revealed a mass of chewed meat at the base of his tongue deep in his larynx. Despite the obstruction being removed with forceps and resuscitation being continued, he was deemed to have sustained an unsurvivable brain injury due to suffering 30 minutes of absolute hypoxia. Treatment was stopped, and he died at 13:40 on 14/09/2020. Following a post mortem, the medical cause of death was determined to be: 1a CHOKING 1b 1c II
Action Should Be Taken
You should:
1. consider how the charging system can be enhanced and strengthened to ensure that staff are provided with properly functioning and charged PIT alarms for their use at the commencement of their shift;
2. consider how and whether additional training/refresher training can be provided to staff - both full time and agency alike - to ensure awareness and compliance with the charging system.
1. consider how the charging system can be enhanced and strengthened to ensure that staff are provided with properly functioning and charged PIT alarms for their use at the commencement of their shift;
2. consider how and whether additional training/refresher training can be provided to staff - both full time and agency alike - to ensure awareness and compliance with the charging system.
Copies Sent To
2. West Midlands Ambulance Service the CQC
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.