UK Inquiry Tracker

Clara Freeman

PFD Report All Responded Ref: 2021-0085

Date of Report 26 March 2021

Coroner Stephen Hugh Glossop Covell

Coroner Area Plymouth Torbay and South Devon

Response Deadline ✓ from report 21 May 2021

Care Home Health related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 21 May 2021

Coroner's Concerns (AI summary)

Concerns were raised about the proficiency of care staff in managing falls, specifically their interaction with ambulance services, accurate medical recording, and awareness of post-fall complications.

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_ [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) Evidence was heard regarding the level of proficiency of the care and nursing staff in dealing with the care of the Deceased after her fall and the interaction of staff with the ambulance service control centre call handlers , particularly in the passing of relevant information and any changes in the Deceased's condition It is requested that the training for care and nursing staff be reviewed to consider; a) Effective interaction with the ambulance service and other medical service providers after an accident or medical emergency b) Accurate recording of medical information including vital signs c) Awareness of the risks of medical complications following falls long lies

Responses

Hart Care Other

26 Mar 2021

Action Taken
All staff members in charge of shifts have attended First Aid Training, which included calling the emergency services, managing falls, fractures, choking, bleeding, dressings, CPR, anaphylaxis, the recovery position and monitoring the patient while awaiting help. (AI summary)

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Dear Mr Covell, In accordance with the Regulation 28 Report to Prevent Future Deaths dated 26th March 2021, write to confirm that we have taken action and all our staff members who are in charge of shifts in the home have attended First Aid Training on the 11thand 13th May 2021 in addition to the mandatory training programme we have in place. Training undertaken recently for staff has consisted of calling the emergency services and managing the emergency until help arrives, how to manage falls, fractures, choking, bleeding, dressings, CPR, anaphylaxis, the recovery position and monitoring the patient while awaiting help. We are currently using a system called "Care Control" for our documentation and care planning and the staff are all trained with what is appropriate and necessary to document_ all understand the importance of appropriate and adequate documentation: Please contact me should you require any further information.

Sent To

Hart Care Nursing and Residential Home

Response Status

Linked responses 1 of 1

56-Day Deadline 21 May 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 13 March 2020 Mr lan Arrow, the senior coroner for Plymouth, South Devon and Torbay commenced an investigation into the death of Clara Ellen Freeman aged 87_ The investigation concluded at the end of the inquest on 19 February 2021.The conclusion of the inquest was the narrative conclusion; Clara Ellen Freeman died at 02.37 on 6 March 2020 on Monkswell Ward, Derriford Hospital, Plymouth. The Deceased suffered an unwitnessed fall at Hart Care Nursing and Residential Home at around 21.30 on 3 March 2020. The Deceased was discovered by care staff but developed medical complications as a consequence of a period of approximately 4 hours being kept on the floor of her room immobilised before an ambulance conveyed her to hospital. The Deceased eventually succumbed in hospital to the medical complications The cause of death was; a Acute Kidney Injury Rhabdomyolysis and Sepsis of Unknown Origin II Heart Failure, Atrial Fibrillation, Frailty and Hypertension

Circumstances of the Death

The Deceased suffered an unwitnessed fall at Hart Care Nursing and Residential Home and was found on the floor of her room on her left side, conscious, but in pain; The ambulance service was contacted at 21.48, which advised that there was heavy demand for the ambulance services at that time and the average waiting time was 2 hours_ Advice was given not to move the Deceased and to dial 999 if the Deceased's condition worsened. An ambulance arrived over 3.5 hours later at 01.23 during which time the Deceased was kept immobile on the floor: The care and nursing staff at the care home made 999 calls at 23.04 and 00.04 to ask when the ambulance arrive and advising that the Deceased was in intense pain and (at 23.04) that the Deceased's temperature and pulse had risen. Observations by the nursing staff also recorded that the Deceased's oxygen saturations reduced during the wait and that latterly the Deceased's colour appeared cyanosed. This information was not handed over in the telephone calls_nor was any concern raised about the risk to the Deceased being_kept immobile over such would

Tong period of time The information would have been important to the call handler to assess whether the Deceased's condition was deteriorating or whether to refer the matter to a clinical adviser and potentially reassess the category of response:

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action;