Averil Skoric
PFD Report
All Responded
Ref: 2019-0383
All 1 response received
· Deadline: 21 Feb 2020
Coroner's Concerns (AI summary)
There is a lack of clear national and local guidance for care home staff on safe sleeping positions for vulnerable adults who lack capacity, increasing the risk of unsafe sleeping.
View full coroner's concerns
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The inquest was told that: Mrs Skoric was a vulnerable resident who lacked capacity. Once she was on her front she was unable to move herself back into a safe sleeping position: She had to be regularly moved during the course of a night to check to see if she needed changing: There was no clear guidance available to care home staff locally or nationally about safe sleeping positioning of vulnerable adults in their care to avoid this cadre of adults being placed in position which created an increased risk of unsafe sleeping:
The inquest was told that: Mrs Skoric was a vulnerable resident who lacked capacity. Once she was on her front she was unable to move herself back into a safe sleeping position: She had to be regularly moved during the course of a night to check to see if she needed changing: There was no clear guidance available to care home staff locally or nationally about safe sleeping positioning of vulnerable adults in their care to avoid this cadre of adults being placed in position which created an increased risk of unsafe sleeping:
Responses
Noted
The Department of Health and Social Care notes the concerns and highlights existing regulations, guidance from NICE, and the role of the Social Care Institute for Excellence (SCIE). (AI summary)
The Department of Health and Social Care notes the concerns and highlights existing regulations, guidance from NICE, and the role of the Social Care Institute for Excellence (SCIE). (AI summary)
View full response
Caroline Dinenage MP Department Minister of State for Care of Health & 39 Victoria Street Social Care London SW1H OEU 020 7210 4850 Your Ref: 9752/MG Ref: PFD-1197061 Ms Alison Mutch OBE 2 2 JAN 2020 HM Senior Coroner; Manchester South HM Coroner's Court HM CORONER 1 Mount Tabor Street MANCHESTER SOUTH Stockport SKI 3AG Sr 2 January 2020 TuSa Thank you for correspondence of 15 November 2019 to about the death of Mrs Averil Skoric. Iam replying as Minister with responsibility for adult social care: Firstly, I would like to extend my deepest sympathies to Mrs Skoric's family and loved ones: We must do all we can to improve the safety and quality of services and Lam grateful to you for bringing these matters to my attention. In considering your concerns, Departmental officials have contacted the Care Quality Commission (CQC) and the National Institute for Health and Care Excellence (NICE): Although there is no specific guidance concerning safe sleeping positions of residents who lack capacity or are at risk the consequences of unsafe sleeping, the CQC expects a provider; for someone with the type of needs that Mrs Skoric had, to meet the fundamental standards as outlined in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This includes: https: WWW legislation gov uklukdsi 2044 9780444447643 contents From Our your from caring
Person-centred care: A provider must do everything reasonably practicable to make sure that people who use the service receive person-centred care and treatment that is appropriate and meets their needs; Safe care and treatment: A provider must do everything reasonably practicable to ensure that care is provided in a safe way; and, Staffing: A provider must deploy enough suitably qualified, competent and experienced staff: The CQC also expects that providers would be able to demonstrate are meeting the relevant Key Lines of Enquiry of the Adult Social Care Assessment Framework?. part of the Line of Enquiry covering the assessment of a person'$ needs and delivering care in line with current legislation, standards and evidence-based guidance, the CQC expects that a person S needs are fully assessed, including risks to their health; safety and wellbeing Inspectors expect a provider to assess the level of risk where someone is unable to reposition themselves in bed, their frailty, and the level of support or supervision to keep them safe. Other Lines of Enquiry include questions on sufficient numbers of adequately trained staff and how people are supported to live healthier lives, have access to healthcare services and receive ongoing healthcare support. The regulations and assessment framework are sufficiently broad to ensure encompass the range of providers that the CQC regulates, the range of services provide and the spectrum of needs experienced by the people receiving services. The CQC expects providers to follow and meet the relevant detailed or best practice guidance that is applicable in a particular care setting or to meet a specific need: Staff who are involved in providing care and support should be appropriately trained and should have the benefit of access to professional support from social workers; occupational therapists and other relevant experts as appropriate Professionals can support the identification of any underlying conditions or ensure that complex needs are identified early and that people are signposted appropriately. In addition, providers are expected to follow the NICE guidance; Dementia: assessment, management and support for people with dementia and their carers (NG97 ) , published in June 2018. This provides guidance to staff caring for https / Www cgc Org uklsites defaultyfiles 20180630asc-registration-assessment-framework-with-sources-of evidence_v0O9 pdf htps: www nice Org uklguidance nE97 they As Key require they Key they they living
people with dementia who have problems and advises staff to consider a personalised multi-component sleep management approach that includes sleep hygiene education, exposure to daylight; exercise and personalised activities. Finally, my officials have brought your concern to the attention of the Social Care Institute for Excellence (SCIE) which provides knowledge resources, training and support to the social care sector to promote the provision of good practice. [ hope this reply is helpful. CAROLINE DINENAGE living sleep Aew CoulaR
Person-centred care: A provider must do everything reasonably practicable to make sure that people who use the service receive person-centred care and treatment that is appropriate and meets their needs; Safe care and treatment: A provider must do everything reasonably practicable to ensure that care is provided in a safe way; and, Staffing: A provider must deploy enough suitably qualified, competent and experienced staff: The CQC also expects that providers would be able to demonstrate are meeting the relevant Key Lines of Enquiry of the Adult Social Care Assessment Framework?. part of the Line of Enquiry covering the assessment of a person'$ needs and delivering care in line with current legislation, standards and evidence-based guidance, the CQC expects that a person S needs are fully assessed, including risks to their health; safety and wellbeing Inspectors expect a provider to assess the level of risk where someone is unable to reposition themselves in bed, their frailty, and the level of support or supervision to keep them safe. Other Lines of Enquiry include questions on sufficient numbers of adequately trained staff and how people are supported to live healthier lives, have access to healthcare services and receive ongoing healthcare support. The regulations and assessment framework are sufficiently broad to ensure encompass the range of providers that the CQC regulates, the range of services provide and the spectrum of needs experienced by the people receiving services. The CQC expects providers to follow and meet the relevant detailed or best practice guidance that is applicable in a particular care setting or to meet a specific need: Staff who are involved in providing care and support should be appropriately trained and should have the benefit of access to professional support from social workers; occupational therapists and other relevant experts as appropriate Professionals can support the identification of any underlying conditions or ensure that complex needs are identified early and that people are signposted appropriately. In addition, providers are expected to follow the NICE guidance; Dementia: assessment, management and support for people with dementia and their carers (NG97 ) , published in June 2018. This provides guidance to staff caring for https / Www cgc Org uklsites defaultyfiles 20180630asc-registration-assessment-framework-with-sources-of evidence_v0O9 pdf htps: www nice Org uklguidance nE97 they As Key require they Key they they living
people with dementia who have problems and advises staff to consider a personalised multi-component sleep management approach that includes sleep hygiene education, exposure to daylight; exercise and personalised activities. Finally, my officials have brought your concern to the attention of the Social Care Institute for Excellence (SCIE) which provides knowledge resources, training and support to the social care sector to promote the provision of good practice. [ hope this reply is helpful. CAROLINE DINENAGE living sleep Aew CoulaR
Sent To
- Department of Health and Social Care
Response Status
Linked responses
1 of 1
56-Day Deadline
21 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 5th March 2018 commenced an investigation into the death of Averil Skoric. The investigation concluded on the 2nd October 2019 and the conclusion was one of Narrative: Died from complications of positional asphyxia contributed to by positioning and her underlying frailty: The medical cause of death was: 1a) Bronchopneumonia with Positional Asphyxia on a background of Frailty and Vascular Dementia; II) Chronic Obstructive Pulmonary Disease
Circumstances of the Death
Averil Skoric had vascular dementia and had become increasingly frail in the months prior to her death. As a result her mobility was very limited. On 3rd March 2018 she was put to bed on her back in the care home where she was residing: On 4th March 2018 she was found on her front; On the balance of probabilities she had rolled onto her front having been left on her side in a way that made it easy for her to move into an unsafe sleeping position: She had died from positional asphyxia as a result
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.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.