Barry Liffen
PFD Report
All Responded
Ref: 2019-0400
All 1 response received
· Deadline: 28 Feb 2020
Coroner's Concerns (AI summary)
A concern was raised regarding the lack of clinical assessment for frail persons resident at Glebelands following falls.
View full coroner's concerns
1. That clinical assessment be sought for frail persons resident at Glebelands following falls.
Responses
Action Planned
• All home managers will be reviewing falls on the PCS (Person Centered Software) system on a weekly basis to ensure that falls are monitored more frequently. • Managers will add notes to the falls log for the week and to the support plans of those residents involved. • Any resident who has more than two falls within a two week period, a review will be arranged with their GP or CPN. (AI summary)
• All home managers will be reviewing falls on the PCS (Person Centered Software) system on a weekly basis to ensure that falls are monitored more frequently. • Managers will add notes to the falls log for the week and to the support plans of those residents involved. • Any resident who has more than two falls within a two week period, a review will be arranged with their GP or CPN. (AI summary)
View full response
Dear Mr Briggs Thankyou for your letter dated 26th November 2019 and the Regulation 28 served for my attention Please accept my apology for the delay in my reply due to my being on Jury Service, Illness and Christmas Holidays: [have investiagted your concerns and agree that each fall had been dealt with appropriately, buta review into the number of falls and the timescale in which the falls occurred did not appear to happen at that time In our other homes the falls would be reviewed at least monthly following the actioning ofthe SMBC Safeguarding Home managers would have escalated the level of falls to the GP or the falls clinic: feel that due to Mr Witon being a new manager this process was overlooked: He had only been with the business a matter ofa few weeks and was still working though his induction process: However; to tighten up our process all home managers will be reviewing falls on our PCS (Person Centered Software) system on a weekly basis to ensure that falls are monitored more frequenty: Managers will the falls log for the week and add notes as to what actions have been taken: These notes will also be added to the support plans of those residents involved: Collectively as a group of managers we have also agreed that any resident who has more than two falls within a two week period we will arrange a review with their GP or CPN. Borough Care Umilod T.0161 4750140 A: 9 Acom Businass Part E:anqulroseboroughcar arguk Heaton Lone. Slockpart SK4 1AS W: borughcoraorguk Letcurtd mbeutbeder Sdelveth coedt ran AetcaOma Anb i PeL HedmL Re57ILIAOAHmn JTA AG JAN _ HM 72020 MANCHESTER: CORONER SOUTH Hogg log: print
This process will be reviewed by our Area Managers as part oftheir monthly audit To aid managers to complete this task weekly [ have added this action to our managers strategic calendar which prompts them daily, weekly monthy etc to actions required hope thatyou feel that we have taken promptactions and reviewed our practise to your satisfaction: Please feel free to contact me ifyou require any further information
This process will be reviewed by our Area Managers as part oftheir monthly audit To aid managers to complete this task weekly [ have added this action to our managers strategic calendar which prompts them daily, weekly monthy etc to actions required hope thatyou feel that we have taken promptactions and reviewed our practise to your satisfaction: Please feel free to contact me ifyou require any further information
Sent To
- Glebelands Care Team
Response Status
Linked responses
1 of 1
56-Day Deadline
28 Feb 2020
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 the 13th November 2019, evidence was heard touching the death of Barry Jack Gordon Liffen. Mr Liffen had died at St George’s Hospital on 11th May 2019, following injuries sustained in a fall at his sheltered accommodation. He was 85 years old.
Medical Cause of Death
I (a) Hospital Acquired Pneumonia (b) Subdural Haemorrhage
II Hypertension, Atrial Fibrillation (anticoagulated)
How, when, where Mr Liffen came by his death:
Mr Liffen suffered with dementia and other chronic illnesses which caused him to be unsteady on mobilising. He was also taking anticoagulants for atrial fibrillation. On 10/3/2019, he fell in the night sustaining a head injury which caused subdural bleeding. This progressed until his condition deteriorated such that an ambulance was called on 22/3/2019. He was admitted to Croydon University Hospital then St George’s Hospital. The bleed stabilised but he developed recurrent pneumonia which ultimately took his life on 11/5/2019 at St George’s Hospital.
Conclusion of the Coroner as to the death:
Accidental fall on a background of chronic medical illnesses and anticoagulation. Extensive evidence was taken in court. In summary, of relevance to this report:
He lived at Glebelands in his own flat with 24 hr carers on site. By Oct/Nov 2018, his care needs increased such that he needed 3 visits a day, help with personal care and taking his medication. In 2019 he fell twice. The first time was 19th January 2019. He was admitted to hospital and had a CT head scan on 21/02/2019 which did not show any acute pathology. He fell again on 10/3/2019 during the night. He was seen by Glebelands staff on the floor and was unable to say how he had fallen. He got himself up and there were no overt injuries but neither clinical assessment nor advise was sought by the attending carers. He was initially well, but from 18th March 2019, he acutely deteriorated, such that by 22/3/2019 an ambulance was called. At this point he could not feed himself, communicate nor mobilise. He was admitted to hospital and found to have an intracranial bleed and his anticoagulation stopped.
It is possible that had the head injury been diagnosed earlier, anticoagulation could have been reversed earlier and the injury been less severe, such that the death may have been avoided.
None of the carers attending Mr Liffen were clinically trained. Concerns of the Coroner:
1. That clinical assessment be sought for frail persons resident at Glebelands following falls.
2. That clinical assessment be sought for persons at Glebelands whose health is noted to have deteriorated by staff.
Medical Cause of Death
I (a) Hospital Acquired Pneumonia (b) Subdural Haemorrhage
II Hypertension, Atrial Fibrillation (anticoagulated)
How, when, where Mr Liffen came by his death:
Mr Liffen suffered with dementia and other chronic illnesses which caused him to be unsteady on mobilising. He was also taking anticoagulants for atrial fibrillation. On 10/3/2019, he fell in the night sustaining a head injury which caused subdural bleeding. This progressed until his condition deteriorated such that an ambulance was called on 22/3/2019. He was admitted to Croydon University Hospital then St George’s Hospital. The bleed stabilised but he developed recurrent pneumonia which ultimately took his life on 11/5/2019 at St George’s Hospital.
Conclusion of the Coroner as to the death:
Accidental fall on a background of chronic medical illnesses and anticoagulation. Extensive evidence was taken in court. In summary, of relevance to this report:
He lived at Glebelands in his own flat with 24 hr carers on site. By Oct/Nov 2018, his care needs increased such that he needed 3 visits a day, help with personal care and taking his medication. In 2019 he fell twice. The first time was 19th January 2019. He was admitted to hospital and had a CT head scan on 21/02/2019 which did not show any acute pathology. He fell again on 10/3/2019 during the night. He was seen by Glebelands staff on the floor and was unable to say how he had fallen. He got himself up and there were no overt injuries but neither clinical assessment nor advise was sought by the attending carers. He was initially well, but from 18th March 2019, he acutely deteriorated, such that by 22/3/2019 an ambulance was called. At this point he could not feed himself, communicate nor mobilise. He was admitted to hospital and found to have an intracranial bleed and his anticoagulation stopped.
It is possible that had the head injury been diagnosed earlier, anticoagulation could have been reversed earlier and the injury been less severe, such that the death may have been avoided.
None of the carers attending Mr Liffen were clinically trained. Concerns of the Coroner:
1. That clinical assessment be sought for frail persons resident at Glebelands following falls.
2. That clinical assessment be sought for persons at Glebelands whose health is noted to have deteriorated by staff.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.