Joseph O’Neill
PFD Report
All Responded
Ref: 2021-0030
All 1 response received
· Deadline: 2 Apr 2021
Coroner's Concerns (AI summary)
Care staff failed to address a heating fault during a heatwave and ensure adequate rehydration, leading to the patient's deterioration being unrecognised.
View full coroner's concerns
Mr O’Neill was attended by carers from Care Outlook four times a day.
It was noted that he was very hot and he was brought a fan. He was also offered respite care in a care home. However, he was fearful of catching COVID19 and in 2020 care home COVID death rates were very high.
When Mr O’Neill refused a place in a care home, the Care Outlook staff did not do anything to resolve the fault with Mr O’Neill’s heating, so it remained on in the middle of a heatwave. An engineer was called to fix his door hinge, but not his heating. Mr O’Neill desperately needed a reduction in the temperature of his flat, first and foremost by the heating being fixed, but Care Outlook staff did not deal with this.
He also needed immediate rehydration. When he was admitted to hospital, he was in deficit by about three litres. He was offered a drink by care staff at mealtimes, but he needed constant prompting and encouragement to drink enough. His deterioration was not recognised.
It was noted that he was very hot and he was brought a fan. He was also offered respite care in a care home. However, he was fearful of catching COVID19 and in 2020 care home COVID death rates were very high.
When Mr O’Neill refused a place in a care home, the Care Outlook staff did not do anything to resolve the fault with Mr O’Neill’s heating, so it remained on in the middle of a heatwave. An engineer was called to fix his door hinge, but not his heating. Mr O’Neill desperately needed a reduction in the temperature of his flat, first and foremost by the heating being fixed, but Care Outlook staff did not deal with this.
He also needed immediate rehydration. When he was admitted to hospital, he was in deficit by about three litres. He was offered a drink by care staff at mealtimes, but he needed constant prompting and encouragement to drink enough. His deterioration was not recognised.
Responses
Action Taken
Care Outlook has introduced a digital care planning system (People Planner), a "Cause for Concern" form for staff, and re-trained staff in incident reporting. They also prepared a factsheet providing enhanced guidance for care workers in relation to the risks of dehydration. (AI summary)
Care Outlook has introduced a digital care planning system (People Planner), a "Cause for Concern" form for staff, and re-trained staff in incident reporting. They also prepared a factsheet providing enhanced guidance for care workers in relation to the risks of dehydration. (AI summary)
View full response
Dear Madam
Inquest into the death of Joseph O’Neil (died 12.08.20)
I write further to the report issued under Regulation 28 of the Coroners (Investigations) Regulations 2013 and to outline the action that has been taken by Care Outlook since the inquest into the death of Joseph O’Neil.
1. Since the incident Care Outlook has introduced a digital care planning and monitoring system; People Planner. The system allows care plans to be accessed by staff on a mobile handset and to record the care delivered in real time. The system has a reporting facility whereby staff are able to complete and submit a report on their handset which is then flagged up on the system and email received by the office in real time. The system has been successfully introduced and is in use by all staff. This will ensure that any concerns raised by staff are recorded immediately and that a permanent record will always be retained. The system also ensure that those concerns are highlighted immediately to care managers.
2. We have also introduced a “Cause for Concern” form for staff to complete, to guide care staff in relation to the types of incident or concern that need to be raised. We are currently working to ensure that the form can be included in the electronic reports on People Planner.
3. All staff in Hackney are being re-trained in the Recording and Reporting of incidents. Initial guidance has been issued in the form of a PowerPoint presentation that has been circulated to all staff. The training outlines the importance of reporting all concerns and ensuring that clear and comprehensive records are made. The training also covers the responsibilities of supervisors and managers to ensure that any concerns raised are resolved and or reported to appropriate third parties (including medical professionals, emergency services, commissioners and safeguarding authorities). Care Outlook 2-10 Laurel Grove, Sydenham, London SE26 4JY Tel: info@careoutlook.co.uk
Care Outlook Ltd. Reg. address: 2-10 Laurel Grove, London, SE26 4JY. Corporation. No. 5302971
We are working to ensure this training can also be delivered as part of our formal e-learning package. Our training lead is preparing an introduction to the training and a supporting competency test, which will form part of our formal induction process. The initial training has been sent to all staff, including care workers, office / field-based supervisors and managers.
4. We have also prepared a factsheet providing enhanced guidance for care workers in relation to the risks of dehydration. The factsheet contains practical guidance on how to spot the signs of dehydration, the routine action that can be taken by care workers to prevent this and the urgent action that must be taken when a client is at risk. The fact sheet has been provided to all care workers.
I hope that this information is of assistance but if you have any questions then please do not hesitate to contact me.
Inquest into the death of Joseph O’Neil (died 12.08.20)
I write further to the report issued under Regulation 28 of the Coroners (Investigations) Regulations 2013 and to outline the action that has been taken by Care Outlook since the inquest into the death of Joseph O’Neil.
1. Since the incident Care Outlook has introduced a digital care planning and monitoring system; People Planner. The system allows care plans to be accessed by staff on a mobile handset and to record the care delivered in real time. The system has a reporting facility whereby staff are able to complete and submit a report on their handset which is then flagged up on the system and email received by the office in real time. The system has been successfully introduced and is in use by all staff. This will ensure that any concerns raised by staff are recorded immediately and that a permanent record will always be retained. The system also ensure that those concerns are highlighted immediately to care managers.
2. We have also introduced a “Cause for Concern” form for staff to complete, to guide care staff in relation to the types of incident or concern that need to be raised. We are currently working to ensure that the form can be included in the electronic reports on People Planner.
3. All staff in Hackney are being re-trained in the Recording and Reporting of incidents. Initial guidance has been issued in the form of a PowerPoint presentation that has been circulated to all staff. The training outlines the importance of reporting all concerns and ensuring that clear and comprehensive records are made. The training also covers the responsibilities of supervisors and managers to ensure that any concerns raised are resolved and or reported to appropriate third parties (including medical professionals, emergency services, commissioners and safeguarding authorities). Care Outlook 2-10 Laurel Grove, Sydenham, London SE26 4JY Tel: info@careoutlook.co.uk
Care Outlook Ltd. Reg. address: 2-10 Laurel Grove, London, SE26 4JY. Corporation. No. 5302971
We are working to ensure this training can also be delivered as part of our formal e-learning package. Our training lead is preparing an introduction to the training and a supporting competency test, which will form part of our formal induction process. The initial training has been sent to all staff, including care workers, office / field-based supervisors and managers.
4. We have also prepared a factsheet providing enhanced guidance for care workers in relation to the risks of dehydration. The factsheet contains practical guidance on how to spot the signs of dehydration, the routine action that can be taken by care workers to prevent this and the urgent action that must be taken when a client is at risk. The fact sheet has been provided to all care workers.
I hope that this information is of assistance but if you have any questions then please do not hesitate to contact me.
Sent To
- Care Outlook Ltd
Response Status
Linked responses
1 of 1
56-Day Deadline
2 Apr 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 20 August 2020, I commenced an investigation into the death of Joseph O’Neill, aged 88 years. The investigation concluded at the end of the inquest earlier today. I made a narrative determination, a copy of which I attach.
Circumstances of the Death
Mr O’Neill developed bronchopneumonia, suffered heat stroke, then became dehydrated and died.
If he had been properly hydrated and had been in an appropriately cool environment, he would not have died when he did.
If he had been properly hydrated and had been in an appropriately cool environment, he would not have died when he did.
Copies Sent To
niece of Joseph O’Neill
Hackney Borough Council
Care Quality Commission for England
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.