Frederick Brooker
PFD Report
All Responded
Ref: 2019-0097
All 1 response received
· Deadline: 9 Aug 2019
Coroner's Concerns (AI summary)
The care home failed to implement adequate falls prevention, lacking care plans despite identified risks. Multiple falls were not properly investigated or reported, and patient safety was compromised by over-reliance on capacity.
View full coroner's concerns
(1) Despite Mr Brooker sustaining multiple falls of increasing severity, no reasonable measures were taken by the Care Home staff to address the high risk of falling: Risk assessments were completed. The high risk was recognised, but there were no care plans to address the identified risk_ (2) There were no steps taken by the Care Home staff to report the multiple falls to the London Borough of Redbridge who were commissioning Mr Brooker'$ care_ There was no referral to wheelchair services to consider whether the wheelchair provided for Mr Brooker was appropriate for him. There was no referral to occupational therapy for a review of Mr Brooker's mobility. Following the falls, there was no evidence of Mr Brooker being encouraged to use his seat belt: (3) An investigation took place into a fall on the 15th March 2018 No further investigations were carried out by the home into the subsequent falls, including those falls resulting in injury: Senior staff were not; therefore; always aware of the circumstances of each fall. They were therefore not able to identify the optimum means of attempting to reduce the risk of further falls.
(4) There was reliance on the fact that Mr Brooker had mental capacity_ This should not override the importance of care planning: Attempts should have been made to plan care to keep Mr Brooker safe. He should have been encouraged to follow the care plan and if he declined, this should have been clearly recorded. Following the falls, there was no evidence ofa care plan to reduce the risk of falling from the wheelchair or evidence of Mr Brooker being encouraged to comply with directions to help to keep him safe: The only record of Mr Brooker declining to use the wheelchair seatbelt; was on the admission assessment (26.1.18). There was no evidence of encouragement after he began to fall from the wheelchair: May from July
(4) There was reliance on the fact that Mr Brooker had mental capacity_ This should not override the importance of care planning: Attempts should have been made to plan care to keep Mr Brooker safe. He should have been encouraged to follow the care plan and if he declined, this should have been clearly recorded. Following the falls, there was no evidence ofa care plan to reduce the risk of falling from the wheelchair or evidence of Mr Brooker being encouraged to comply with directions to help to keep him safe: The only record of Mr Brooker declining to use the wheelchair seatbelt; was on the admission assessment (26.1.18). There was no evidence of encouragement after he began to fall from the wheelchair: May from July
Responses
Action Taken
HC-One implemented an action plan at Bakers Court to address the concerns highlighted. Multi-factorial Falls Risk Assessments will inform the development and implementation of a daily plan of care. (AI summary)
HC-One implemented an action plan at Bakers Court to address the concerns highlighted. Multi-factorial Falls Risk Assessments will inform the development and implementation of a daily plan of care. (AI summary)
View full response
Dear Miss Persaud; write to inform YOU of the actions taken at HC-One in response to your Regulafion 28 report prevent future deaths: Please find enclosed an action plan; which has been implemented at Bakers Court to address the concerns you highlighted [Exhibit 1]. Since the date of Mr Brooker's death; HC-One has undertaken a lot of internally on the topic of falls and increased its focUs on falls awareness and prevention In particular; efforts been made to improve falls awareness across the organisation, minimise falls so far as possible and to ensure the appropriate management of falls across the organisation: Regrettably, it is not uncommon for older people to experience a fall, for a variety of reasons_ Such falls cannot always be prevented but as an organisation we are committed to supporting people to maintain their safety wherever possible and to ensure that our Colleagues respond appropriately in the event that a fall does occUr: HC-One is committed to enabling Residents to live & full and active life. We embrace the concept of keeping Residents as independent and as mobile as possible whilst minimising the risk to their health, safety and wellbeing Multi-factorial Risk Assessments It is important to identify all Residents who may be at a risk of falling and as such, thorough assessments should be conducted: A Multi-factorial Falls Risk Assessment [Exhibit 2] will inform the development and implementation of a daily plan of care_ The risk assessment that is used in HC-One has all of the factors indicated through the National Institute for Health and Care Excellence (NICE): HC-One 101325 351100 F 01325 351144 Correspondence & Registered Office: Southgate House, Archer Street, Darlington, County Durham; DL3 6AH Registered in England and Wales: HC-One Limited; registration no. 07712656; Meridian Healthcare Limited, registration no. 01952719; HC-One Beamish Limited, registration no. 05217764; HC Oval Limited, registration no. 10257888; RV Care Homes Limited, registration no. 07417290. work have ~One
HC The kind one care tompanyt The falls guidance, risk assessment; policy and guidance has been developed using the Care Inspectorate guidance, Managing Falls and Fractures" and this has been implemented widely across the UK: AIl Residents must have a full and comprehensive Falls Risk Assessment completed prior to admission: Residents identified to be 'at risk on the Pre-Admission Assessment, must then be re-assessed on admission in their new environment. At HC-One we consider any risk within the Multi-factorial Risk Assessment as potential reason for people to fall and as such requires to be managed: It is clearly recorded on the risk assessment that if any risks are identified then a Falls Care and Support Plan needs to be developed: Residents identified as having any of the factors that are considered to be a risk must have a full review on a monthly basis, or more frequently as the Resident's condition dictates_ Our policies are clear that a new assessment must be completed following fall and/or if the physical or psychological condition of the Resident changes plan of care must be in place for mobilising; including the use of mobilisation aids_ The Use of walking aids and other equipment should be considered, after assessment by a physiotherapist or occupational therapist where potential risk has been identified. The use of assistive technology should be considered where appropriate. This can include call mats, seating and bed sensors, room sensor beams, low beds, anti-roll mattresses or non-standard equipment; which is recommended by external professionals All assessments and reviews must be fully documented and recorded in the Resident' s care file_ Our Risk Assessments will identify predisposing factors, which may lead to falls, such as the use of a wheelchair which requires the use of lap straps.
b. Post Fall Protocol Following a fall, immediate action must be taken to ensure the safety and comfort of the Resident_ Staff must not leave the Resident unattended and immediate assistance should be summoned: It is important that the Resident is assessed and examined promptly to see if are injured: This will help to inform decisions about safe handling and ensure any injuries are treated in a timely manner: Our policies are clear that all falls must be properly recorded and investigated. As soon as possible, after the fall, an incident report should be logged on our Datix incident reporting system: The incident report should be comprehensive and give a clear picture of what happened and what immediate action was taken:
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HC kind one care tompant The incident must be investigated in order to identify what happened, how it happened and why it happened: The intention is to learn from the incident and take action in order to reduce the likelihood of further falls and/or minimise the risk of harm in the future Care plans and risk assessments will be reviewed and reformulated as necessary Particular attention should be given to Residents who have experienced more than one fall in a week or more than three in a month. The more falls Resident has had the greater the falls risk. Even if a fall is minor and causes no injury, it is our policy that the Home Manager must still investigate and try to prevent it happening again: A Post Fall Protocol Flow Chart [Exhibit 3] is available and provides useful at-a-glance guidance for staff teams to remind them of the steps to follow after a fall. In order to ensure compliance with the process, & checklist has been developed to provide prompts to the care home team on documentation and process [Exhibit 4] and to ensure that our staff teams are actively thinking about each of the actions required after a fall: Trend analysis Datix can be Utilised in order to cary out trend analysis: An analysis of falls will help Home Managers to identify any trends and any areas of concern to target, from which can take suitable action. can also monitor whether the preventative actions have taken are having the desired effect in reducing the number of falls and the harm caused following a fall. Home Managers are able to analyse the falls of a particular Resident or look at all falls in a home. Datix can show many things, including where falls are happening, their location, the time of falls and the level of harm caused. For example, a fall analysis may identify that many falls are taking place in a particular location around the same time of day: Home Managers are encouraged and supported to use these tools. d: Review of care practices, specifically relating to falls Following any incident that has affected Resident health or well-being, an incident record must be uploaded onto the Datix system_ This system captures any untoward event that occurs, whether it causes harm or not predominately this is falls, ill health, medicine errors, safeguarding and complaints Once the incident is entered on Datix, the appropriate area and specialist teams are notified and depending on the nature/severity of the incident, this will advise who will undertake the investigation Falls are reported at group level, area level, home level and finally to Resident level through our internal reporting systems where we can Ultimately see how the individual Resident'$ care is supported: 3 of 4 The they They they Page
HC The kind one care tsmpant At home level there is & three monthly full audit of falls, including falls team meeting and monthly review through the Clinical Indicators report, which will identify key high risk Residents for the home to follow up on, and as part of the Resident of the monthly review process the care plan will be checked. We have implemented a monthly clinical review where falls are & part of the review with the senior team at home level the Area Quality Director supports with this and monitors outcomes At area level; the Area Director/ Area Quality Director'$ review falls as part of their home visits and our internal inspection team of Quality Regulation Managers review this on their inspection visits . believe that the governance around falls management broke down through poor reporting and have looked at re training and shared learning for the home team and manager'$ with oversight to drive this forward to improvement_ Falls and serious incident trends are discussed quarterly at the Quality Governance Group comprising members of senior management and lessons are shared across the organisation. We continually review the NICE guidance in relation to falls and implement new technologies to support Residents_ Further support All of the falls processes have been summarised onto one page documents called Here's How To_ These are available to all care teams and will be reviewed twice a year [Exhibit 5]. The Clinical Quality Team supports with falls root cause analysis for any fracture or serious injury sustained following a fall:. support with the investigation and outcomes, and report back through the quality governance structure Where any shortfalls in individual practice or non-compliance with the process are identified, this will be followed up and appropriate actions taken: Falls training is provided to all direct care teams in the form of an online module and face to face falls awareness training sessions. Actions and oversight by the company is ongoing in respect of the above matters, to ensure ongoing compliance with company expectations do hope this information is helpful and offers YOU the reassurance that we, at HC-One, have taken the issues raised very seriously and have taken appropriate action with the intention of improving the care and safety of our Residents.
HC The kind one care tompanyt The falls guidance, risk assessment; policy and guidance has been developed using the Care Inspectorate guidance, Managing Falls and Fractures" and this has been implemented widely across the UK: AIl Residents must have a full and comprehensive Falls Risk Assessment completed prior to admission: Residents identified to be 'at risk on the Pre-Admission Assessment, must then be re-assessed on admission in their new environment. At HC-One we consider any risk within the Multi-factorial Risk Assessment as potential reason for people to fall and as such requires to be managed: It is clearly recorded on the risk assessment that if any risks are identified then a Falls Care and Support Plan needs to be developed: Residents identified as having any of the factors that are considered to be a risk must have a full review on a monthly basis, or more frequently as the Resident's condition dictates_ Our policies are clear that a new assessment must be completed following fall and/or if the physical or psychological condition of the Resident changes plan of care must be in place for mobilising; including the use of mobilisation aids_ The Use of walking aids and other equipment should be considered, after assessment by a physiotherapist or occupational therapist where potential risk has been identified. The use of assistive technology should be considered where appropriate. This can include call mats, seating and bed sensors, room sensor beams, low beds, anti-roll mattresses or non-standard equipment; which is recommended by external professionals All assessments and reviews must be fully documented and recorded in the Resident' s care file_ Our Risk Assessments will identify predisposing factors, which may lead to falls, such as the use of a wheelchair which requires the use of lap straps.
b. Post Fall Protocol Following a fall, immediate action must be taken to ensure the safety and comfort of the Resident_ Staff must not leave the Resident unattended and immediate assistance should be summoned: It is important that the Resident is assessed and examined promptly to see if are injured: This will help to inform decisions about safe handling and ensure any injuries are treated in a timely manner: Our policies are clear that all falls must be properly recorded and investigated. As soon as possible, after the fall, an incident report should be logged on our Datix incident reporting system: The incident report should be comprehensive and give a clear picture of what happened and what immediate action was taken:
they
HC kind one care tompant The incident must be investigated in order to identify what happened, how it happened and why it happened: The intention is to learn from the incident and take action in order to reduce the likelihood of further falls and/or minimise the risk of harm in the future Care plans and risk assessments will be reviewed and reformulated as necessary Particular attention should be given to Residents who have experienced more than one fall in a week or more than three in a month. The more falls Resident has had the greater the falls risk. Even if a fall is minor and causes no injury, it is our policy that the Home Manager must still investigate and try to prevent it happening again: A Post Fall Protocol Flow Chart [Exhibit 3] is available and provides useful at-a-glance guidance for staff teams to remind them of the steps to follow after a fall. In order to ensure compliance with the process, & checklist has been developed to provide prompts to the care home team on documentation and process [Exhibit 4] and to ensure that our staff teams are actively thinking about each of the actions required after a fall: Trend analysis Datix can be Utilised in order to cary out trend analysis: An analysis of falls will help Home Managers to identify any trends and any areas of concern to target, from which can take suitable action. can also monitor whether the preventative actions have taken are having the desired effect in reducing the number of falls and the harm caused following a fall. Home Managers are able to analyse the falls of a particular Resident or look at all falls in a home. Datix can show many things, including where falls are happening, their location, the time of falls and the level of harm caused. For example, a fall analysis may identify that many falls are taking place in a particular location around the same time of day: Home Managers are encouraged and supported to use these tools. d: Review of care practices, specifically relating to falls Following any incident that has affected Resident health or well-being, an incident record must be uploaded onto the Datix system_ This system captures any untoward event that occurs, whether it causes harm or not predominately this is falls, ill health, medicine errors, safeguarding and complaints Once the incident is entered on Datix, the appropriate area and specialist teams are notified and depending on the nature/severity of the incident, this will advise who will undertake the investigation Falls are reported at group level, area level, home level and finally to Resident level through our internal reporting systems where we can Ultimately see how the individual Resident'$ care is supported: 3 of 4 The they They they Page
HC The kind one care tsmpant At home level there is & three monthly full audit of falls, including falls team meeting and monthly review through the Clinical Indicators report, which will identify key high risk Residents for the home to follow up on, and as part of the Resident of the monthly review process the care plan will be checked. We have implemented a monthly clinical review where falls are & part of the review with the senior team at home level the Area Quality Director supports with this and monitors outcomes At area level; the Area Director/ Area Quality Director'$ review falls as part of their home visits and our internal inspection team of Quality Regulation Managers review this on their inspection visits . believe that the governance around falls management broke down through poor reporting and have looked at re training and shared learning for the home team and manager'$ with oversight to drive this forward to improvement_ Falls and serious incident trends are discussed quarterly at the Quality Governance Group comprising members of senior management and lessons are shared across the organisation. We continually review the NICE guidance in relation to falls and implement new technologies to support Residents_ Further support All of the falls processes have been summarised onto one page documents called Here's How To_ These are available to all care teams and will be reviewed twice a year [Exhibit 5]. The Clinical Quality Team supports with falls root cause analysis for any fracture or serious injury sustained following a fall:. support with the investigation and outcomes, and report back through the quality governance structure Where any shortfalls in individual practice or non-compliance with the process are identified, this will be followed up and appropriate actions taken: Falls training is provided to all direct care teams in the form of an online module and face to face falls awareness training sessions. Actions and oversight by the company is ongoing in respect of the above matters, to ensure ongoing compliance with company expectations do hope this information is helpful and offers YOU the reassurance that we, at HC-One, have taken the issues raised very seriously and have taken appropriate action with the intention of improving the care and safety of our Residents.
Sent To
- HC-One
Response Status
Linked responses
1 of 1
56-Day Deadline
9 Aug 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 18th August 2018 commenced an investigation into the death of Mr Frederick Raymond BROOKER The investigation concluded at the end ofthe inquest on the 12th March 2019. The conclusion of the inquest was: Mr Frederick Brooker had sustained multiple falls from his wheelchair, whilst residing in @ Care Home. fall from the wheelchair on the 1 July 2018 had resulted in a hospital attendance for @ head injury: Following this fall, the care plan was not updated; the wheelchair assessment review was not updated and Mr Brooker was not encouraged to wear the seat belt He sustained a further fall from his wheelchair on the 10 July 2018. He required hospital admission for @ further head injury: A subdural haemorrhage was identified at this time. He died from this head injury on the 14 July 2018.
Circumstances of the Death
Mr Brooker was admitted to the Bakers Court Residential Care Home on the 26th January 2018. He required the use of a wheelchair to mobilise around the Care Home. The General Practitioner noted on the 16"h March 2018 that Mr Brooker had fallen from his wheelchair when reaching to pick up a book from the floor. The General Practitioner was told at that time that similar slides from the wheelchair had happened several times before: At this time, Mr Brooker did not sustain any injury and the GP noted a low impact fall: Mr Brooker was strongly encouraged to ask for assistance if something fell to the floor_ No other strategies were identified, at that time, to reduce the risk of further falls On 20"" March 2018 the GP noted that Mr Brooker had slid from his wheelchair twice in the last few davs The falls were again noted to be low impact and had occurred whilst he was leaning forward reaching for_
items_ On the 5tn April 2018 Mr Brooker fell again from his wheelchair. At this time he was noted to have sustained a head injury and paramedics were called. On the 29th 2018 Mr Brooker fell again his wheelchair No injuries were noted at this time. On the 1s July 2018 Mr Brooker fell again from his wheelchair and at this time sustained a head injury: He was taken to Newham University Hospital where a CT scan was carried out: Mr Brooker was on Warfarin and therefore at high risk of bleeding from head injury: No bleed was found at this time and he was discharged back to the home on the 1st July 2018. The Falls Risk Assessment was updated on the 1 July 2018 and it was noted that Mr Brooker remained at high risk of falling There was however no review ofthe care plan in place to address his risk of falling; there was no review to his wheelchair assessment; there was no documented need for the seatbelt to be used by Mr Brooker; there was no evidence of any encouragement for Mr Brooker to use the seatbelt. Mr Brooker' $ son raised concerns with the Care Home on the 1 2018 in relation to the multiple falls: In response to these concerns the Care Home staff agreed to liaise with wheelchair services. No action was however taken by the Care Home staff to liaise with wheelchair services On the 10th July 2018,Mr Brooker suffered a further fall from his wheelchair. He sustained a head injury and was returned to Newham University Hospital. At this time, it was noted that Mr Brooker had sustained a catastrophic traumatic bleed: He passed away from the head injury on the 14th July 2018.
items_ On the 5tn April 2018 Mr Brooker fell again from his wheelchair. At this time he was noted to have sustained a head injury and paramedics were called. On the 29th 2018 Mr Brooker fell again his wheelchair No injuries were noted at this time. On the 1s July 2018 Mr Brooker fell again from his wheelchair and at this time sustained a head injury: He was taken to Newham University Hospital where a CT scan was carried out: Mr Brooker was on Warfarin and therefore at high risk of bleeding from head injury: No bleed was found at this time and he was discharged back to the home on the 1st July 2018. The Falls Risk Assessment was updated on the 1 July 2018 and it was noted that Mr Brooker remained at high risk of falling There was however no review ofthe care plan in place to address his risk of falling; there was no review to his wheelchair assessment; there was no documented need for the seatbelt to be used by Mr Brooker; there was no evidence of any encouragement for Mr Brooker to use the seatbelt. Mr Brooker' $ son raised concerns with the Care Home on the 1 2018 in relation to the multiple falls: In response to these concerns the Care Home staff agreed to liaise with wheelchair services. No action was however taken by the Care Home staff to liaise with wheelchair services On the 10th July 2018,Mr Brooker suffered a further fall from his wheelchair. He sustained a head injury and was returned to Newham University Hospital. At this time, it was noted that Mr Brooker had sustained a catastrophic traumatic bleed: He passed away from the head injury on the 14th July 2018.
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.