Robert Rostron
PFD Report
All Responded
Ref: 2019-0237
All 1 response received
· Deadline: 8 Nov 2019
Coroner's Concerns (AI summary)
Critical over-reliance on inadequately inducted agency nurses as senior staff led to unfamiliarity with essential policies, records, and patient care plans, resulting in medication errors.
View full coroner's concerns
During the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken: : During the inquest, evidence was heard that (at nursing homes under the control of HC One): Agency Nurses are still used if needed to lead a shift, when have never worked on the unit before_ An Agency Nurse might still be the only qualified member of nursing staff on duty on the unit There_is_reliance_upon nursing_qualification_and_the_aqency_providing_the day: being 17th they
Agency Nurse regarding nursing ability, suitability and training:. In this instance, the only induction to the Unit was by way of Healthcare Assistant showing the Agency Nurse around on the morning of the shift
5. The Agency Nurse did not appreciate the relevance of the blood sugar level of 2.2, The Agency Nurse did not appreciate that no insulin should have been given in light of the reading of 2.2 The Agency Nurse did not know where the nursing records were, the care plans for the patients or the relevant policies and procedures in place The Agency Nurse did not know that it was the policy of Seasons Nursing Home that insulin should only have been given by whilst a Healthcare Assistant was present to check the dose_ am concerned by the use of Agency Nurses in the homes under the management of HC One_ In particular, am concerned by the lack of formal induction and orientation to the unit on this occasion. am concerned that reliance is placed upon the nursing qualification itself and the agency providing the nurse am concerned that an Agency Nurse was used as the senior member of staff in charge of the shift. am concerned that the Agency Nurse was giving out medication when he had never worked at the Unit before and. am concerned that there were nO other qualified nurses on the Spring Unit at the time. request that HC One conducts a review f the use of Agency Nurses_in their homes
Agency Nurse regarding nursing ability, suitability and training:. In this instance, the only induction to the Unit was by way of Healthcare Assistant showing the Agency Nurse around on the morning of the shift
5. The Agency Nurse did not appreciate the relevance of the blood sugar level of 2.2, The Agency Nurse did not appreciate that no insulin should have been given in light of the reading of 2.2 The Agency Nurse did not know where the nursing records were, the care plans for the patients or the relevant policies and procedures in place The Agency Nurse did not know that it was the policy of Seasons Nursing Home that insulin should only have been given by whilst a Healthcare Assistant was present to check the dose_ am concerned by the use of Agency Nurses in the homes under the management of HC One_ In particular, am concerned by the lack of formal induction and orientation to the unit on this occasion. am concerned that reliance is placed upon the nursing qualification itself and the agency providing the nurse am concerned that an Agency Nurse was used as the senior member of staff in charge of the shift. am concerned that the Agency Nurse was giving out medication when he had never worked at the Unit before and. am concerned that there were nO other qualified nurses on the Spring Unit at the time. request that HC One conducts a review f the use of Agency Nurses_in their homes
Responses
Action Taken
HC-One has implemented actions including requiring two colleagues to support all insulin administrations, creating a Home Improvement Plan for insulin administration safety, and revising the agency procedure to include robust checks. They also use an agency procedure since 2016 which is being revised and have implemented agency profiles to be held within the quality assurance system. (AI summary)
HC-One has implemented actions including requiring two colleagues to support all insulin administrations, creating a Home Improvement Plan for insulin administration safety, and revising the agency procedure to include robust checks. They also use an agency procedure since 2016 which is being revised and have implemented agency profiles to be held within the quality assurance system. (AI summary)
View full response
Dear Ms. Galloway,
Regulation 28 Prevention of future death report following inquest into the death of Robert Charles Rostron
I write in response to your letter of 11 July 2019 requesting written information and supporting evidence about action taken since the death of Mr. Rostron to reduce the risk of a similar incident occurring.
With regard to Four Seasons in particular, you will probably be aware that the Discharge to Assess service, where the incident occurred, is no longer being delivered. Whilst we continually work hard to reduce agency use, we also recognise that the reality of running care homes means that this remains a necessity to ensure that there are always sufficient staff available to support the needs of the people accommodated. We are required to pay a premium for nurse qualified staff in such circumstances, because of the assurances this provides in relation to training and fitness to practice to ensure their continued registration.
We, at HC-One, have been and remain committed to acting in whatever ways possible to ensure that we reduce the possibility of any recurrence of this incident and maintain the safety of all our Residents.
I will respond to each of your concerns in turn.
1. Agency nurses are still used, if necessary to lead a shift, when they have never worked on the unit before There are still unfortunately occasions when we are required to call upon the need to cover nursing shifts at this and other homes with agency nurses. However, we have implemented a series of additional measures to reduce the likelihood of an agency nurse being required to lead a shift without having worked at the home or individual House before.
All agency staff are block booked as far as possible to maximise knowledge of HC-One standards and also individual Residents’ needs across individual homes.
It is still possible that an agency nurse might lead a shift at a home, but we have reduced the risk by reviewing and strengthening the Orientation booklet for agency staff, which is due for completion and distribution across the company by the end of October 2019.
2. An agency nurse might still be the only qualified member of the nursing staff on duty on the unit. It is possible that an agency nurse might be the only qualified nurse on duty, however this is much less likely now. Nevertheless, many of our homes operate with rigorously trained nursing assistants, who have completed NMC accredited training that includes medicine giving, which includes clarity on the need for there to always be two staff present when administering this medicine. In addition, an agency nurse is always supplied with contact details of other nurses working within the same home, senior managers outside of the home who are on call on a rota basis and available to offer advice 24 hours a day for seven days a week. Details of this are posted in the nurse station, which is included in the orientation booklet that both the agency nurse and senior staff member sharing are required to sign and a copy is kept on the agency nurses file at the home, as well as them being supplied their own copy for reference.
3. There is reliance upon a nursing qualification and agency providing the Agency Nurse regarding nursing ability, suitability and training. The procedure now adopted after close liaison with agency suppliers is that all agency nurses who wish to work in HC-One homes are required to complete and submit a record of training, which specifically stipulates whether they have the skills, knowledge and up to date training to administer insulin safely. These training records and qualifications are audited annually and we can and do suspend use of agencies if there is any discrepancy or failure to complete. We currently have three agencies suspended for failing to comply in part with this agreement. I have attached a copy of the checklist for your attention (Appendix 1). This negates any reliance on the nursing qualification by specifically ensuring we have verified training and qualifications. We stipulate the required nursing qualification on making the booking with the agency and the Home Manager has the facility to choose from a series of profiles and makes a positive choice of nurse who has provided evidence as having the necessary and appropriate registered general nursing qualification as a minimum.
Concerns 4 – 8: In this instance, the only induction to the Unit was by way of a Healthcare Assistant showing the Agency Nurse around on the morning of the shift. The agency nurse did not appreciate the relevance of the blood sugar level of 2.2. The agency nurse did not appreciate that no insulin should have been given in light of reading 2.2. The agency nurse did not know where the records were, the care plan for the patients or the relevant policies and procedures in place. The agency nurse did not know that it was policy of HC-One that insulin should only be given by him whilst a Nursing Assistant was present to check the dose. As part of the agency nurse’s orientation to the home, the location of all risk assessments, care plans, the diabetes resource file, physical posters regarding hypo/hyperglycaemia management, hypo box, medicines and policies and procedures would be shown, as mentioned previously, to them by the most senior member of staff at the home, to support them in their shift, which would be the Home Manager, Deputy Home Manager or Nurse in charge of the home. This ensures that any agency nurse is fully orientated and knows where to locate important documents as well as summoning support within the home. I have supplied a copy of our Administration of High Risk Medicines procedure (Appendix
2) as there is a relevant section regarding insulin, indicating the necessity for all insulin administration to be supported by two colleagues. This is covered in the checklist now because of the lessons learned from the agency worker deviating from the procedure. Operational colleagues overseeing this home crafted and completed a Home Improvement Plan for Four Seasons, which detailed many of the actions we had determined would both improve safety of Residents who required support with insulin administration and management and have attached an updated version (Appendix 3), which provides assurances around the completion of these actions and outcomes. Since 2016, we have developed and implemented an agency procedure and although this was not due for a review until next year, a revision is in train to revise and this has already resulted in improvements in ensuring robust checks to agencies. I have attached (Appendix
4) the current version, not in place at the time of the incident, and will be happy to supply the updated version when finalised. The agency profiles already in operation and expected standard practice in all our homes, will be required to be held alongside the completed orientation booklet and held within the quality assurance system, Cornerstone. We have developed the system to allow the agency worker to also retain a copy of their booklet.
I trust this information is helpful and offers the necessary assurances that we have taken the situation extremely seriously and continue to review and strive to make continued improvements in the best interests of our Residents.
Regulation 28 Prevention of future death report following inquest into the death of Robert Charles Rostron
I write in response to your letter of 11 July 2019 requesting written information and supporting evidence about action taken since the death of Mr. Rostron to reduce the risk of a similar incident occurring.
With regard to Four Seasons in particular, you will probably be aware that the Discharge to Assess service, where the incident occurred, is no longer being delivered. Whilst we continually work hard to reduce agency use, we also recognise that the reality of running care homes means that this remains a necessity to ensure that there are always sufficient staff available to support the needs of the people accommodated. We are required to pay a premium for nurse qualified staff in such circumstances, because of the assurances this provides in relation to training and fitness to practice to ensure their continued registration.
We, at HC-One, have been and remain committed to acting in whatever ways possible to ensure that we reduce the possibility of any recurrence of this incident and maintain the safety of all our Residents.
I will respond to each of your concerns in turn.
1. Agency nurses are still used, if necessary to lead a shift, when they have never worked on the unit before There are still unfortunately occasions when we are required to call upon the need to cover nursing shifts at this and other homes with agency nurses. However, we have implemented a series of additional measures to reduce the likelihood of an agency nurse being required to lead a shift without having worked at the home or individual House before.
All agency staff are block booked as far as possible to maximise knowledge of HC-One standards and also individual Residents’ needs across individual homes.
It is still possible that an agency nurse might lead a shift at a home, but we have reduced the risk by reviewing and strengthening the Orientation booklet for agency staff, which is due for completion and distribution across the company by the end of October 2019.
2. An agency nurse might still be the only qualified member of the nursing staff on duty on the unit. It is possible that an agency nurse might be the only qualified nurse on duty, however this is much less likely now. Nevertheless, many of our homes operate with rigorously trained nursing assistants, who have completed NMC accredited training that includes medicine giving, which includes clarity on the need for there to always be two staff present when administering this medicine. In addition, an agency nurse is always supplied with contact details of other nurses working within the same home, senior managers outside of the home who are on call on a rota basis and available to offer advice 24 hours a day for seven days a week. Details of this are posted in the nurse station, which is included in the orientation booklet that both the agency nurse and senior staff member sharing are required to sign and a copy is kept on the agency nurses file at the home, as well as them being supplied their own copy for reference.
3. There is reliance upon a nursing qualification and agency providing the Agency Nurse regarding nursing ability, suitability and training. The procedure now adopted after close liaison with agency suppliers is that all agency nurses who wish to work in HC-One homes are required to complete and submit a record of training, which specifically stipulates whether they have the skills, knowledge and up to date training to administer insulin safely. These training records and qualifications are audited annually and we can and do suspend use of agencies if there is any discrepancy or failure to complete. We currently have three agencies suspended for failing to comply in part with this agreement. I have attached a copy of the checklist for your attention (Appendix 1). This negates any reliance on the nursing qualification by specifically ensuring we have verified training and qualifications. We stipulate the required nursing qualification on making the booking with the agency and the Home Manager has the facility to choose from a series of profiles and makes a positive choice of nurse who has provided evidence as having the necessary and appropriate registered general nursing qualification as a minimum.
Concerns 4 – 8: In this instance, the only induction to the Unit was by way of a Healthcare Assistant showing the Agency Nurse around on the morning of the shift. The agency nurse did not appreciate the relevance of the blood sugar level of 2.2. The agency nurse did not appreciate that no insulin should have been given in light of reading 2.2. The agency nurse did not know where the records were, the care plan for the patients or the relevant policies and procedures in place. The agency nurse did not know that it was policy of HC-One that insulin should only be given by him whilst a Nursing Assistant was present to check the dose. As part of the agency nurse’s orientation to the home, the location of all risk assessments, care plans, the diabetes resource file, physical posters regarding hypo/hyperglycaemia management, hypo box, medicines and policies and procedures would be shown, as mentioned previously, to them by the most senior member of staff at the home, to support them in their shift, which would be the Home Manager, Deputy Home Manager or Nurse in charge of the home. This ensures that any agency nurse is fully orientated and knows where to locate important documents as well as summoning support within the home. I have supplied a copy of our Administration of High Risk Medicines procedure (Appendix
2) as there is a relevant section regarding insulin, indicating the necessity for all insulin administration to be supported by two colleagues. This is covered in the checklist now because of the lessons learned from the agency worker deviating from the procedure. Operational colleagues overseeing this home crafted and completed a Home Improvement Plan for Four Seasons, which detailed many of the actions we had determined would both improve safety of Residents who required support with insulin administration and management and have attached an updated version (Appendix 3), which provides assurances around the completion of these actions and outcomes. Since 2016, we have developed and implemented an agency procedure and although this was not due for a review until next year, a revision is in train to revise and this has already resulted in improvements in ensuring robust checks to agencies. I have attached (Appendix
4) the current version, not in place at the time of the incident, and will be happy to supply the updated version when finalised. The agency profiles already in operation and expected standard practice in all our homes, will be required to be held alongside the completed orientation booklet and held within the quality assurance system, Cornerstone. We have developed the system to allow the agency worker to also retain a copy of their booklet.
I trust this information is helpful and offers the necessary assurances that we have taken the situation extremely seriously and continue to review and strive to make continued improvements in the best interests of our Residents.
Sent To
- HC-One
Response Status
Linked responses
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56-Day Deadline
8 Nov 2019
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 25th July 2018 an investigation was commenced into the death of Robert Charles Rostron, aged 72 years, born on the gth May 1946 The investigation concluded at the end of the Inquest on the 3rd July 2019. The Medical Cause of Death was: Ia Sepsis 1b Pneumonia and Pyelonephritis Ic Alzheimers Disease II Type Diabetes_ Administration of insulin on 7th September 2017_ The conclusion at the inquest was that Robert Rostron died as a consequence of natural causes, exacerbated by the administration of insulin on a background of Type diabetes_
Circumstances of the Death
Robert Rostron (hereinafter referred to as "the Deceased") died at Fairfield General Hospital, Rochdale Old Road, on the 20uh July 2018. The Deceased suffered from naturally occurring Type Diabetes, for which he required regular monitoring and treatment: From mid-September 2017 he was a resident at the Four Seasons Nursing Home (which is a home under the management of HC One) on the Spring Unit (which is no longer in existence) As well as Type Diabetes_ the Deceased suffered from Alzheimers Disease and his position was such that he required nursing care and support in a nursing home environment On the 17th September 2017 an Agency Nurse was in charge of the Spring Unit: He started his shift shortly after 8 am: That member of staff was a qualified nurse , with experience in mental health matters but with limited experience of physical health matters He was the only qualified nurse on duty on Spring Unit Bury
(albeit that there were other nurses present on adjacent units): He was in charge of the shift, with the support of healthcare assistants_ He was also in charge of giving prescribed medications to patients on Spring unit that In evidence, the Agency Nurse confirmed that he had not worked on Spring Unit before. He had only ever undertaken one other agency-nursing shift; which was the day before and at a different place_ On that occasion, he did have the support of another qualified nurse On the 17th September 2017, he confirmed that he did not know where any of the patients' records were kept, he did not read the patients' records and he had no access to any care plans in respect of the patients he was caring for.
5. On the morning of the 17h September 2017, the Agency Nurse undertook the medication round: He had been shown where the medication was stored by a Healthcare Assistant and had been introduced to patients on the unit: During the course of the medication round (which he undertook alone), he had reference to the Deceased's medication record, which was stored by his bed He did not have regard to the nursing records nor to any care plans contained therein, as he did not know where they were stored (they were apparently present the nursing office). There was care plan in place for the management of the Deceased's diabetes_ but he did not have regard to that He took the Deceased's blood sugar reading and noted this to be 2.2 (which is low) He then proceeded to give the Deceased what he considered to be his usual dose of insulin (8 units). This was not in accordance with the Care Plan in place and the evidence at the inquest was such that qualified nurse would be expected to know that a reading of 2.2 units was a low reading and that insulin shouid have been withheld (and further measures taken, such as provision of a sugary drink to increase the blood sugar level): It was not until a few hours later that the Agency Nurse checked again on the Deceased. By this stage , the Deceased was unconscious and unresponsive: An ambulance was called and he was taken to Royal Bolton Hospital: On the basis of the evidence heard, concluded that the Deceased never recovered to his previous baseline_ He spent time at two further nursing homes following his admission to Royal Bolton Hospital before admitted to Fairfield Hospital on the 25ih June 2018. On the basis of the clinical evidence heard it was my finding that the events of the September 2017 caused increased frailty and indirectly contributed to the Deceased'$ death. found that the Deceased never regained his previous baseline and the administration of insulin on the 17th September was the cause of that: It made him more susceptible to the infections that he developed ad led to his death on the 251h June 2018 at Fairfield Hospital: He would not have died when he did, but for the insulin administration on the 17th September 2017.
(albeit that there were other nurses present on adjacent units): He was in charge of the shift, with the support of healthcare assistants_ He was also in charge of giving prescribed medications to patients on Spring unit that In evidence, the Agency Nurse confirmed that he had not worked on Spring Unit before. He had only ever undertaken one other agency-nursing shift; which was the day before and at a different place_ On that occasion, he did have the support of another qualified nurse On the 17th September 2017, he confirmed that he did not know where any of the patients' records were kept, he did not read the patients' records and he had no access to any care plans in respect of the patients he was caring for.
5. On the morning of the 17h September 2017, the Agency Nurse undertook the medication round: He had been shown where the medication was stored by a Healthcare Assistant and had been introduced to patients on the unit: During the course of the medication round (which he undertook alone), he had reference to the Deceased's medication record, which was stored by his bed He did not have regard to the nursing records nor to any care plans contained therein, as he did not know where they were stored (they were apparently present the nursing office). There was care plan in place for the management of the Deceased's diabetes_ but he did not have regard to that He took the Deceased's blood sugar reading and noted this to be 2.2 (which is low) He then proceeded to give the Deceased what he considered to be his usual dose of insulin (8 units). This was not in accordance with the Care Plan in place and the evidence at the inquest was such that qualified nurse would be expected to know that a reading of 2.2 units was a low reading and that insulin shouid have been withheld (and further measures taken, such as provision of a sugary drink to increase the blood sugar level): It was not until a few hours later that the Agency Nurse checked again on the Deceased. By this stage , the Deceased was unconscious and unresponsive: An ambulance was called and he was taken to Royal Bolton Hospital: On the basis of the evidence heard, concluded that the Deceased never recovered to his previous baseline_ He spent time at two further nursing homes following his admission to Royal Bolton Hospital before admitted to Fairfield Hospital on the 25ih June 2018. On the basis of the clinical evidence heard it was my finding that the events of the September 2017 caused increased frailty and indirectly contributed to the Deceased'$ death. found that the Deceased never regained his previous baseline and the administration of insulin on the 17th September was the cause of that: It made him more susceptible to the infections that he developed ad led to his death on the 251h June 2018 at Fairfield Hospital: He would not have died when he did, but for the insulin administration on the 17th September 2017.
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:
Copies Sent To
HC One Justin Hutchens, Chief Executive, HC
One, Southgate House, Archer Street, Darlington DL 3 64H
Dated 11th July 2019 Signed: Rachel Galloway 'U & HM Assistant Coroner Manchester West
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.