Stanley Langdon
PFD Report
Partially Responded
Ref: 2018-0110
Coroner's Concerns (AI summary)
A day care centre provided services without receiving or creating an adequate care plan based on a needs assessment or family discussion, risking future similar accidents.
View full coroner's concerns
(1) On 6th March 2017, the deceased was in the care of the Haven Day Care Centre who were providing respite care services to the deceased that were being funded by Durham County Council: (2) Prior to the commencement of services provided to the deceased by the Haven Care Centre, no care plan or assessment of the deceased's needs had been received from Durham County Council by the Haven Day Care Centre.
(3) The Haven Care Centre began to provide services to the deceased on guh January 2017 , without having any adequate care plan or assessment of the deceased s needs in place (4) The inquest was told in evidence that Durham County Council had systems in place to ensure that service providers such as the Haven Day Care Centre would not be Day June Home May being Day Day authorised to provide services unless and until they had received a care plan and assessment of needs in relation t0 any specific service user: (5) The inquest was also told in evidence that the systems referred to in (4) were not being applied consistently, and service providers (specifically Haven Day Care Centre) were still commencing the provision of services t0 service users without receiving care plans and assessments f need for particular service users.
(6) The care plan that was put in place for the deceased at the Haven Care Centre after services had begun to be provided to him was not based on all the information that was or should have been available, and that the said care plan had not been discussed and agreed with the deceased's family (it being noted that the deceased was a dementia sufferer heavily reliant on his family for care from to day) It appears to me that there is a risk that similar situations as that applying to the deceased may arise in the future, whereby the Haven Care Centre may begin to provide services to a service user without having been provided with relevant information in the form of a care plan and needs assessment from Durham County Council, and without having in place their own care plan and needs assessment based on complete information and adequate discussion with a service user's family (in circumstances where the service user was heavily reliant on the family for care from to day): (8) In my opinion the above risk itself creates a risk that accidents similar to that which befell the deceased on 6ih March 2017 may occur in the future, and that there is a risk that future similar incidents may result in the death of a service user in circumstances similar to the deceased's death:
(3) The Haven Care Centre began to provide services to the deceased on guh January 2017 , without having any adequate care plan or assessment of the deceased s needs in place (4) The inquest was told in evidence that Durham County Council had systems in place to ensure that service providers such as the Haven Day Care Centre would not be Day June Home May being Day Day authorised to provide services unless and until they had received a care plan and assessment of needs in relation t0 any specific service user: (5) The inquest was also told in evidence that the systems referred to in (4) were not being applied consistently, and service providers (specifically Haven Day Care Centre) were still commencing the provision of services t0 service users without receiving care plans and assessments f need for particular service users.
(6) The care plan that was put in place for the deceased at the Haven Care Centre after services had begun to be provided to him was not based on all the information that was or should have been available, and that the said care plan had not been discussed and agreed with the deceased's family (it being noted that the deceased was a dementia sufferer heavily reliant on his family for care from to day) It appears to me that there is a risk that similar situations as that applying to the deceased may arise in the future, whereby the Haven Care Centre may begin to provide services to a service user without having been provided with relevant information in the form of a care plan and needs assessment from Durham County Council, and without having in place their own care plan and needs assessment based on complete information and adequate discussion with a service user's family (in circumstances where the service user was heavily reliant on the family for care from to day): (8) In my opinion the above risk itself creates a risk that accidents similar to that which befell the deceased on 6ih March 2017 may occur in the future, and that there is a risk that future similar incidents may result in the death of a service user in circumstances similar to the deceased's death:
Responses
Action Taken
The Haven Day Centre implemented all suggested improvements from a County Durham Commissioning team report, including obtaining signatures on risk assessments, reviewing complaints policies, unifying transport policies, improving training records, and revising home assessment documents. (AI summary)
The Haven Day Centre implemented all suggested improvements from a County Durham Commissioning team report, including obtaining signatures on risk assessments, reviewing complaints policies, unifying transport policies, improving training records, and revising home assessment documents. (AI summary)
View full response
Oliver Longstaff HM Assistant Coroner County Durham & Darlington
14th June 2018
Regulation 28 Report Response re Stanley Langdon and Haven Day Centre Following the accident involving Mr Stanley Langdon and prior to the Coroner’s inquest taking place, the Haven received a visit and inspection of current practices regarding admission of new clients and associated protocols from County Durham Commissioning team. A report was received, and ALL suggested improvements were made as the documents attached confirm ref SCAN20170623, this was in place prior to the inquest date. The changes included:
1. Obtaining signatures from service users/representatives on all service user risk assessments.
2. Complaints policies response timescales reviewed and amended
3. Unification of all transport policy documents into a single policy
4. All training records included within a summary document
5. Review of staff training on risk assessment regarding service users
6. Review and refresher on staff Health & Safety training
7. Review and refresher on Moving and Handling for all staff
8. Increase of number of staff supervisions per annum from 3 to 4
9. Introduction of a revised home assessment document for completion prior to new placements
10. Change of policy regarding accepting new placements unless all relevant documentation is in place
11. Review of all existing and new placements regarding provision of a suitable care plan with regard to the method of accessing mini bus via steps or tail lift
12. Logging of all incidents relating to client behaviour to identify frequency and trends and any required modification to ongoing care plan, A copy of the documents referred to is attached as SCAN20170623. I trust that this meets with your approval.
Chairperson On behalf of The Haven Day Centre Burnhope
14th June 2018
Regulation 28 Report Response re Stanley Langdon and Haven Day Centre Following the accident involving Mr Stanley Langdon and prior to the Coroner’s inquest taking place, the Haven received a visit and inspection of current practices regarding admission of new clients and associated protocols from County Durham Commissioning team. A report was received, and ALL suggested improvements were made as the documents attached confirm ref SCAN20170623, this was in place prior to the inquest date. The changes included:
1. Obtaining signatures from service users/representatives on all service user risk assessments.
2. Complaints policies response timescales reviewed and amended
3. Unification of all transport policy documents into a single policy
4. All training records included within a summary document
5. Review of staff training on risk assessment regarding service users
6. Review and refresher on staff Health & Safety training
7. Review and refresher on Moving and Handling for all staff
8. Increase of number of staff supervisions per annum from 3 to 4
9. Introduction of a revised home assessment document for completion prior to new placements
10. Change of policy regarding accepting new placements unless all relevant documentation is in place
11. Review of all existing and new placements regarding provision of a suitable care plan with regard to the method of accessing mini bus via steps or tail lift
12. Logging of all incidents relating to client behaviour to identify frequency and trends and any required modification to ongoing care plan, A copy of the documents referred to is attached as SCAN20170623. I trust that this meets with your approval.
Chairperson On behalf of The Haven Day Centre Burnhope
Sent To
- Durham County Council
- Haven Day Care Centre
Response Status
Linked responses
1 of 2
56-Day Deadline
12 Aug 2018
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 1s1 of 2017 | commenced an investigation into the death of Stanley Langdon, aged 93 years. The investigation concluded at the end of the inquest on 17h April 2018. The conclusion of the inquest was Medical cause of death Ia Bronchopneumonia 1b Immobility following operatively repaired periprosthetic left femoral fracture: Conclusion Accident
Circumstances of the Death
Stanley Langdon died at the Dipton Manor Care on 215 2017 from complications arising from a periprosthetic left femoral fracture sustained on 6th March 2017 when he was being assisted by carers t0 climb the steps onto a minibus. Had he been mobilised on to the minibus in a wheelchair via the available hydraulic lift he would not have sustained that fracture.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action:
Copies Sent To
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.