John Doyle
PFD Report
Partially Responded
Ref: 2019-0226
Coroner's Concerns (AI summary)
Inadequate and outdated training for occupational therapists on emergency Telecare equipment, including ordering processes and compatibility, poses a risk due to rapidly changing technology.
View full coroner's concerns
put days:
: : The MATTER OF CONCERN is the evidence heard around the provided to occupational therapists in relation to the emergency equipment available from Telecare: It is requested that the training for occupational therapists is reviewed to consider: The emergency alarm equipment available The order process required for such equipment; and II. The compatibility between the alarm system and the telephone systems within the home setting It was also noted that technology changes frequently and therefore it is requested that a form of refresher training is also considered.
: : The MATTER OF CONCERN is the evidence heard around the provided to occupational therapists in relation to the emergency equipment available from Telecare: It is requested that the training for occupational therapists is reviewed to consider: The emergency alarm equipment available The order process required for such equipment; and II. The compatibility between the alarm system and the telephone systems within the home setting It was also noted that technology changes frequently and therefore it is requested that a form of refresher training is also considered.
Responses
Action Planned
North East London NHS Foundation Trust (NELFT) has provided an action plan to address issues identified in the Regulation 28 report, and established a working group around pendant alarms. (AI summary)
North East London NHS Foundation Trust (NELFT) has provided an action plan to address issues identified in the Regulation 28 report, and established a working group around pendant alarms. (AI summary)
View full response
Dear all; Please read the patient safety alert below, particularly for OT colleagues or any other clinicians in our services who carry out pendant alarm assessments and referrals. This is related to a patient incident within our CHS inpatient wards, however; it is applicable to all ofour services where there are referrals for pendant alarms We have & action plan from the coroners inquest which we will be completing and also working with Laura Stuart Neil - AHP Lead to look into the processes asa NELFT wide learning: We will be picking this up in my DBM next month to share the learning from the case, but feel it is important to raise awareness before then. Please can you discuss in your team meetings and ensure that our OT colleagues have seen the alert: There will be another formal alert released from QPS, however, please share within your teams in the meantime:
NELFT Wi Patient NHS Faundation Tl safety alert Bulleun numbet 2019-001 Issue Vata: 10,07,.2019 Target audlcnce; KD'9, ADs ard all OT a Ir comnunlty and scutt Purposelkey Issuors" Risk of delay of Installation of a pendant alarm for patients in the community setting: Introduction: Thare have been to recent patlent safely Indldents concemlng Ihe prescrlbing and supplylng of Ihe pendant alarm syslem lor communlty residlng pallents. Action requlred: In order b reduce my essodated isk Iha bllowlng urgertt actton [= requlred: ocaupational ttarapist responsible for requesling provielon d a pendant alarm vla thelr local aulhorty musl ensure Ihat Ihe alarm is ordered pramply followIna ussessmenl end mual en8ur0 lo epecify clarty on tna relerral Icxmn tha palleni"& existing lelophone syetem, The occupalinal Iherapist muet check wilh Ihe palien andior lamily membor; prilor Io torwarding te rcleral; whelhcr Ihby hava & #orking Iand Ina phora. If the >alient don$ not have & working landlire phone Ihon Ihc occupalbnal Ihcraplst musl chock It tno pallant has & molilo phona compallble wilh the pendant alarm syctem Iesled in tat local authonlyiccallly: ncilncr landlino ncr mobile phond (s in place lha occupallonal Iherapisl should consull Iho palicai andfr tamilly I0 conllmm urgent arrangemante {or a sullable Iandllng or moblle phone lo onebla the Fendart alam request to ba mada. Il neceasary Ihe ocupallonal tharaplsl muet refer p Iho Icczl autharily (or a8sjatance wlth Botllng Ihls UP: Please relor lo your local autharlly guldance on their Frocass (or Issuing pondant alerms. Thls will be monltored via tho Quallty & Patlent Safety team a.dlt ot Ihe mlnutes ol DBM' : meeting, Any
From: Sent: ZU August ZUI9 13.50 To: Cc: Subject: Telecdlle urcmnng Hi Team OT OT's have a Telecare training on 27.08.2019 at 12.00-12.30 in the Japonica Meeting room with Jlease put this in your diary and attend: Thanks to providing this Kind Regards Band Physiotherapist NELFT NHS Foundation Trust Acute and Rehabilitation Directorate Foxglove and Japonica Wards King Georges Hospital Ilford, I63 8YB. Tel: 0300,555 1201 Ext. 58704 Working Pattern: Tuesday Friday 08.00-16.00
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NELFT NHS Best care by the best people NHS Foundation Trust NELFT IRS Occupational Therapy Meeting Block 8 Meeting Room Wednesday 18/9/2019,3pm AGENDA Person Time Title of item Time presenting limit
1. Apologies Minutes of the last meeting
3. Matters arising IRS Equipment 30 minutes
4.1 Review of previously clinically reasoned equipment
4.2 Plan for next equipment to be reviewed
4.3 Update on telecare process for BHR boroughs
5. Training needs NELFT 20 pharmacy minutes
5.1 NELFT pharmacy presentation for medication aids team OT caseload minutes
6.1 Delegation to Rehab Assistants AOB minutes
8. Date and time of next meeting First Wednesday of every month at 3pm
NELFT NHS] Best care by the best people NHS Foundation Trust NELFT IRS Occupational Therapy Meeting Block 8 Meeting Room Wednesday 18/9/2019, 3pm AGENDA Person Time Title of item presenting Time Vimit
1. Apologies
2. Minutes of the last meeting Matters arising
4. IRS Equipment 30 minutes
4.1 Review of previously clinically reasoned equipment
4.2 Plan for next equipment to be reviewed
4.3 Update on telecare process for BHR boroughs
5. Training needs NELFT 20 pharmacy minutes
5.1 NELFT pharmacy presentation for medication aids team
6. OT caseload minutes 6,1 Delegation to Rehab Assistants AOB minutes Date and time of next meeting First Wednesday of every month at 3pm
p 1 2 3 1 1 [ 2 1 2 1 2 L 2 1 3 1 g L 1 2 2 3 1 5 V 2 2 8 2 1 WH 1 8 1 6 3 11 1 H 8 3 3 @ 6 07 0 L 0 1 We { H 2 8 1 H 3 8 3 Hiinideui 3 1 3 8 3 1 2 1 1 1 V 1 3 51 1h hg 1
8 M 8 1 4 3 4 3 13 4 | 3 3 2 8 1 6 J [ [ ] 9 88 1 [ H 2 [ [ 1
Sent: 25 lulv 2019 19.38 To: Cc: Subject: RE: Pendant alarm working group Many thanks! will be in touch_ Director of Quality Improvement/ Director of Allied Health Professions & Psychological Therapies NELFT NHS Foundation Trust Email: Please note do not normally wOrk on Fridays_ WWW nelft nhs uk /qualit y-improvement @laurajstuart; @nelftqip, @NELFT_AHP Member of the London Clinical Senate Council WWW londonsenate nhs_uk Contact for Ql enquiries: For other enquiries: Mare NELFT NHSI NILAt oulity Member of nicmtbct NHS Foundation Trust Improntnkni RCOT Roqusmtt 4 #allchat ua From: Sent: 22 July ZUIS I;o Subject: Pendant alarm working group en who are both occupational therapists within the Intensive Rehab Service are keen and interested to be part ofthe working group around pendant alarms: Please let me know if there is any other information you are copied into this email as well as vho is the service lead. Many thanks Occupational Therapist Intensive Rehabilitation Service North East London Foundation Trust Acute and Rehabilitation Directorate Goodmayes Hospital Block 8 Barley Lane QY need.
Sent: 24 September 2019 15.45 To: Subject: Response to 28 Report your ref 9469 Attachments: Regulation 28 Report Feedback August 2019pdf; D83196 Regulation 28 action plan 27.08.19-pdf Good afternoon Regulation 28 Report your reference 9469 Thank you for taking the time to speak with me: Further to our conversation, please find attached the letter and action plan sent by NELFT in response to the Regulation 28 Report; do apologise if this did not reach you when sent originally: would be very grateful if you could bring this to the attention of HM Coroner with our sincere apologies for the delay: would be grateful if you could confirm safe receipt: If you require anything further on this matter then please do let me know Kind regards Deputy Head of Corporate Affairs NELFT North East London NHS Foundation Trust CEME Centre, West Marsh Rainham,Essex, RM13 8GQ wwwnelft nhsuk NELFT [HS NHS Foundsstion Trust Best care by the best people healthy WorkpLace AcxitvaneKt 3018 Mayor OFLONDON This email and any attachments are or may be confidential and legally privileged and are sent solely for the attention of the addressee(s): If you have received this email in error, please delete it from your system: its use, disclosure or copying is unauthorised. Statements and opinions expressed in this email may not represent those of NELFT, representations or commitments in this email are subject to contract: NELFT NHS Foundation Trust From: Reg Wing; Way, Any
NELFT Wi Patient NHS Faundation Tl safety alert Bulleun numbet 2019-001 Issue Vata: 10,07,.2019 Target audlcnce; KD'9, ADs ard all OT a Ir comnunlty and scutt Purposelkey Issuors" Risk of delay of Installation of a pendant alarm for patients in the community setting: Introduction: Thare have been to recent patlent safely Indldents concemlng Ihe prescrlbing and supplylng of Ihe pendant alarm syslem lor communlty residlng pallents. Action requlred: In order b reduce my essodated isk Iha bllowlng urgertt actton [= requlred: ocaupational ttarapist responsible for requesling provielon d a pendant alarm vla thelr local aulhorty musl ensure Ihat Ihe alarm is ordered pramply followIna ussessmenl end mual en8ur0 lo epecify clarty on tna relerral Icxmn tha palleni"& existing lelophone syetem, The occupalinal Iherapist muet check wilh Ihe palien andior lamily membor; prilor Io torwarding te rcleral; whelhcr Ihby hava & #orking Iand Ina phora. If the >alient don$ not have & working landlire phone Ihon Ihc occupalbnal Ihcraplst musl chock It tno pallant has & molilo phona compallble wilh the pendant alarm syctem Iesled in tat local authonlyiccallly: ncilncr landlino ncr mobile phond (s in place lha occupallonal Iherapisl should consull Iho palicai andfr tamilly I0 conllmm urgent arrangemante {or a sullable Iandllng or moblle phone lo onebla the Fendart alam request to ba mada. Il neceasary Ihe ocupallonal tharaplsl muet refer p Iho Icczl autharily (or a8sjatance wlth Botllng Ihls UP: Please relor lo your local autharlly guldance on their Frocass (or Issuing pondant alerms. Thls will be monltored via tho Quallty & Patlent Safety team a.dlt ot Ihe mlnutes ol DBM' : meeting, Any
From: Sent: ZU August ZUI9 13.50 To: Cc: Subject: Telecdlle urcmnng Hi Team OT OT's have a Telecare training on 27.08.2019 at 12.00-12.30 in the Japonica Meeting room with Jlease put this in your diary and attend: Thanks to providing this Kind Regards Band Physiotherapist NELFT NHS Foundation Trust Acute and Rehabilitation Directorate Foxglove and Japonica Wards King Georges Hospital Ilford, I63 8YB. Tel: 0300,555 1201 Ext. 58704 Working Pattern: Tuesday Friday 08.00-16.00
B 1 ] 8 9 1 3 1 2 lii 19 Il 9 3 8 J j 9 J 2 1 2 8 13 1 Il | 8 1 3 3 iHH f 3 1 E8 8 ( W 0 3 9 1 8 0 ( 8 3 8 9 2 1 9 2 ] 29 1 8 1 8 0 6 1L 8 T J 2 J 1 H 5 WH 2 2 2
Bw1 22 8 1 1 3 Ih1 U 3 Wa 6 4 2 ( 0 1 Hh 9 Jl 6 1 2 2 9 @ 3 1 2 1 J 8 1 2 08 1 2 { 1 [ # 2 1 9 2 L [ 2 3 1 3 1 8 8 @ 3 98 Ji 8 9 L J 96 H #I 27
9 E 1 { 8 L 1 8 8 Ji 5 { 1 3 4 h 2 1 H 1 L
1 1 3 2 1 2 E MH g ] 1 j 29 8 3 1 1 h 88 23 Ii 1 4 il g U L 1 4 | 1 H { I HH # (
4 3 9 1 3 I 1 9 1 ( I1 HHu
1 98 4
NELFT NHS Best care by the best people NHS Foundation Trust NELFT IRS Occupational Therapy Meeting Block 8 Meeting Room Wednesday 18/9/2019,3pm AGENDA Person Time Title of item Time presenting limit
1. Apologies Minutes of the last meeting
3. Matters arising IRS Equipment 30 minutes
4.1 Review of previously clinically reasoned equipment
4.2 Plan for next equipment to be reviewed
4.3 Update on telecare process for BHR boroughs
5. Training needs NELFT 20 pharmacy minutes
5.1 NELFT pharmacy presentation for medication aids team OT caseload minutes
6.1 Delegation to Rehab Assistants AOB minutes
8. Date and time of next meeting First Wednesday of every month at 3pm
NELFT NHS] Best care by the best people NHS Foundation Trust NELFT IRS Occupational Therapy Meeting Block 8 Meeting Room Wednesday 18/9/2019, 3pm AGENDA Person Time Title of item presenting Time Vimit
1. Apologies
2. Minutes of the last meeting Matters arising
4. IRS Equipment 30 minutes
4.1 Review of previously clinically reasoned equipment
4.2 Plan for next equipment to be reviewed
4.3 Update on telecare process for BHR boroughs
5. Training needs NELFT 20 pharmacy minutes
5.1 NELFT pharmacy presentation for medication aids team
6. OT caseload minutes 6,1 Delegation to Rehab Assistants AOB minutes Date and time of next meeting First Wednesday of every month at 3pm
p 1 2 3 1 1 [ 2 1 2 1 2 L 2 1 3 1 g L 1 2 2 3 1 5 V 2 2 8 2 1 WH 1 8 1 6 3 11 1 H 8 3 3 @ 6 07 0 L 0 1 We { H 2 8 1 H 3 8 3 Hiinideui 3 1 3 8 3 1 2 1 1 1 V 1 3 51 1h hg 1
8 M 8 1 4 3 4 3 13 4 | 3 3 2 8 1 6 J [ [ ] 9 88 1 [ H 2 [ [ 1
Sent: 25 lulv 2019 19.38 To: Cc: Subject: RE: Pendant alarm working group Many thanks! will be in touch_ Director of Quality Improvement/ Director of Allied Health Professions & Psychological Therapies NELFT NHS Foundation Trust Email: Please note do not normally wOrk on Fridays_ WWW nelft nhs uk /qualit y-improvement @laurajstuart; @nelftqip, @NELFT_AHP Member of the London Clinical Senate Council WWW londonsenate nhs_uk Contact for Ql enquiries: For other enquiries: Mare NELFT NHSI NILAt oulity Member of nicmtbct NHS Foundation Trust Improntnkni RCOT Roqusmtt 4 #allchat ua From: Sent: 22 July ZUIS I;o Subject: Pendant alarm working group en who are both occupational therapists within the Intensive Rehab Service are keen and interested to be part ofthe working group around pendant alarms: Please let me know if there is any other information you are copied into this email as well as vho is the service lead. Many thanks Occupational Therapist Intensive Rehabilitation Service North East London Foundation Trust Acute and Rehabilitation Directorate Goodmayes Hospital Block 8 Barley Lane QY need.
Sent: 24 September 2019 15.45 To: Subject: Response to 28 Report your ref 9469 Attachments: Regulation 28 Report Feedback August 2019pdf; D83196 Regulation 28 action plan 27.08.19-pdf Good afternoon Regulation 28 Report your reference 9469 Thank you for taking the time to speak with me: Further to our conversation, please find attached the letter and action plan sent by NELFT in response to the Regulation 28 Report; do apologise if this did not reach you when sent originally: would be very grateful if you could bring this to the attention of HM Coroner with our sincere apologies for the delay: would be grateful if you could confirm safe receipt: If you require anything further on this matter then please do let me know Kind regards Deputy Head of Corporate Affairs NELFT North East London NHS Foundation Trust CEME Centre, West Marsh Rainham,Essex, RM13 8GQ wwwnelft nhsuk NELFT [HS NHS Foundsstion Trust Best care by the best people healthy WorkpLace AcxitvaneKt 3018 Mayor OFLONDON This email and any attachments are or may be confidential and legally privileged and are sent solely for the attention of the addressee(s): If you have received this email in error, please delete it from your system: its use, disclosure or copying is unauthorised. Statements and opinions expressed in this email may not represent those of NELFT, representations or commitments in this email are subject to contract: NELFT NHS Foundation Trust From: Reg Wing; Way, Any
Part of a Series
2 separate reports were issued from this inquest, each sent to different organisations.
-
2024-0618
Sent to: British Transplant SocietyGeorge Eliot Hospital NHS TrustNHS EnglandRenal AssociationUK Kidney AssociationAll responded
This report (2019-0226) is shown above.
Sent To
- North East London NHS Trust
Response Status
Linked responses
1 of 2
56-Day Deadline
8 Nov 2019
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 21/01/2019 commenced an investigation into the death of John Patrick Doyle. The investigation concluded at the end of the inquest 2Sth June 2019. The conclusion of the inquest was a narrative conclusion: Mr Doyle died as a result of starvation ketoacidosis, following a likely fall in his home address It is likely that he was unable to get up or seek assistance, following the fall He had suffered a similar fall and long-lie, some months prior to his death. The need for a panic alarm was identified, but no alarm had been in place at the time of his death:
Circumstances of the Death
Mr Doyle was admitted to hospital in July 2018 having fallen at his home address. Following the fall, he had laid undiscovered for 4 to 5 He was discharged from Hospital on the 10 September 2018. Prior to his discharge, there was recognition of a need for a panic alarm. A panic alarm was requested, by the occupational therapist with an urgency level of "high" on the 4 September 2018 There were initial difficulties in reaching Mr Doyle; but a home visit to arrange the alarm took place on 18 September 2018_ A different type of alarm was recommended, because Mr Doyle did not have a landline: Advice was provided to the occupational therapist on how to request this, on the 27 September 2018. The occupation therapist did not lodge the request until 4 October 2018. Sadly, Mr Dovle was found deceased by a district nurse on the 3 October 2018. It is likely that he had suffered a fall and was unable to get back up or to seek assistance: He died from starvation ketoacidosis_
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.