Ronald Jones
PFD Report
All Responded
Ref: 2017-0416
All 1 response received
· Deadline: 24 Apr 2018
Coroner's Concerns (AI summary)
Lack of first aid training for staff moving residents after falls poses a risk of exacerbating injuries, as the city council discontinued this essential training.
View full coroner's concerns
The MATTERS OF CONCERNS are as follows: I was told in evidence at Mr JONES inquest that following his fall, he was moved to his bed by personnel who had not undergone first aid training as this had been discontinued by Portsmouth City Council. If persons are moved following a fall, unless this is done correctly, there is a risk that they may be injured or their existing injuries exacerbated, potentially fatally. The Council should consider re-activating this training for all staff involved with residents in the City council's sheltered housing schemes.
Responses
Noted
The council acknowledges the coroner's concerns but states that current training for sheltered housing staff is adequate for their roles, which do not include lifting residents who have fallen. (AI summary)
The council acknowledges the coroner's concerns but states that current training for sheltered housing staff is adequate for their roles, which do not include lifting residents who have fallen. (AI summary)
View full response
Dear Mr Horsley REGULATION 28 REPORT MR R JONES Thank you for your report regarding the investigation into the death of Mr R Jones and the concerns raised regarding training for the sheltered housing staff. have investigated this matter and have found the following: have discussed this with Deputy Chief Executive and also made the Director of Adult Social Care aware for reasons that will be clear in the response below. appreciate that there is a level of detail here which may adjust the action you proposed and in light of that would be happy to meet with you and Michael if that is helpful: General points Portsmouth City Council Housing Service Sheltered Housing Staff__ roles responsibilities and training The sheltered housing staff only provide housing related support to help residents maintain independent living in our sheltered schemes. All sheltered housing staff attend a 'responding to accidents and sudden illness' course which covers the typical type of incidents that arise in the schemes All sheltered housing staff receive 'handling people' training which involves both theoretical and practical training: This training takes place for new members of staff and then every member of staff attends refresher training on this topic every 3 years. In addition to this, sheltered housing staff undertake Falls Prevention Awareness training which looks at risks and how these can be minimised_ The training is only to support residents that just need support to get up following fall and does not equip the sheltered housing staff to lift residents that have fallen. We do not expect nor train our sheltered housing staff to lift residents
Sheltered Housing Schemes In our Category 2.5 schemes such as Arthur Dann Court, there is on site staff presence 24 hours with a Scheme Manager and a team of Support Assistants_ Between 22.00 and 7.00,on site cover is provided by a carer who is employed by a Care Agency: The carer is an employee of a care agency who have been commissioned by Adult Social Care to provide care to clients in the area. The service provided is a sleep in service, with the carer responding to calls from residents via the in house alarm system_ In the event that a resident has fallen and cannot get themselves up and are in pain, then sheltered housing staff will contact the emergency services to send a paramedic, or in the event of a fall between the hours of 21.00 and 6.00 then will contact the Night Responder Team for Support: The Night Responder Team is a service provided by Adult Social Care. The team are trained to respond to situations where a resident has fallen and the resident requires support to lift them: They do have first aid training and operate in pairs In our category & 2 schemes there isnt a 24 hour staffing presence and out of hours the resident would pull a cord which links to a response centre and would send the appropriate emergency service to attend if appropriate. The specific Sheltered Housing_Scheme and the Incident Arthur Dann Court is category 2.5 sheltered scheme. The residents have their own flats and as outlined above there is on site housing support provided by PCC housing sheltered housing staff between the hours of 7.00 and 22.00 with a care agency-employed sleep in carer as the first point of response between the hours of
22.00 and 7.00. The carer is first aid trained. Some residents in Arthur Dann Court and other sheltered housing schemes need help with their personal care and in these circumstances, a care package is arranged by Adult Social Care and this care is delivered by the zoned care agency commissioned by Adult Social Care. The Specific Incident on 25 January 2017 At 22.30, Ronald Jones of called for help and the sleep in carer found him in his bathroom hanging onto his frame with his right arm stuck The carer put a pillow on the floor in case he fell and she managed to free his arm s0 that he was able to sit on the floor: On finding Mr Jones in this situation, the carer did not attempt to lift Mr Jones and took the correct action by calling the Night Responder Team for support: Two Team Leaders from this team arrived at 23.00 and the report from this team reads: Received call from night warden, on arrival client on floor in bathroom, checked all over bruising to lower right arm, assisted to stand from floor; walked with frame through to bedroom, client very unsteady on his feet, when settled in bed client complained of pain in his back came over hot and sweaty and breathing changed, night warden called paramedics to attend, left client with paramedics and night warden, left property 00.35. day, they they they
Summary In light of these findings it does not seem that additional training in first aid for Portsmouth Council Housing sheltered housing staff teams is required: The training have is tailored to their role and responsibilities. The Night Responder Team who did attend to Mr Jones do have the appropriate training to lift Mr Jones and are first aid trained: Please do not hesitate to contact me should you require any future information
Sheltered Housing Schemes In our Category 2.5 schemes such as Arthur Dann Court, there is on site staff presence 24 hours with a Scheme Manager and a team of Support Assistants_ Between 22.00 and 7.00,on site cover is provided by a carer who is employed by a Care Agency: The carer is an employee of a care agency who have been commissioned by Adult Social Care to provide care to clients in the area. The service provided is a sleep in service, with the carer responding to calls from residents via the in house alarm system_ In the event that a resident has fallen and cannot get themselves up and are in pain, then sheltered housing staff will contact the emergency services to send a paramedic, or in the event of a fall between the hours of 21.00 and 6.00 then will contact the Night Responder Team for Support: The Night Responder Team is a service provided by Adult Social Care. The team are trained to respond to situations where a resident has fallen and the resident requires support to lift them: They do have first aid training and operate in pairs In our category & 2 schemes there isnt a 24 hour staffing presence and out of hours the resident would pull a cord which links to a response centre and would send the appropriate emergency service to attend if appropriate. The specific Sheltered Housing_Scheme and the Incident Arthur Dann Court is category 2.5 sheltered scheme. The residents have their own flats and as outlined above there is on site housing support provided by PCC housing sheltered housing staff between the hours of 7.00 and 22.00 with a care agency-employed sleep in carer as the first point of response between the hours of
22.00 and 7.00. The carer is first aid trained. Some residents in Arthur Dann Court and other sheltered housing schemes need help with their personal care and in these circumstances, a care package is arranged by Adult Social Care and this care is delivered by the zoned care agency commissioned by Adult Social Care. The Specific Incident on 25 January 2017 At 22.30, Ronald Jones of called for help and the sleep in carer found him in his bathroom hanging onto his frame with his right arm stuck The carer put a pillow on the floor in case he fell and she managed to free his arm s0 that he was able to sit on the floor: On finding Mr Jones in this situation, the carer did not attempt to lift Mr Jones and took the correct action by calling the Night Responder Team for support: Two Team Leaders from this team arrived at 23.00 and the report from this team reads: Received call from night warden, on arrival client on floor in bathroom, checked all over bruising to lower right arm, assisted to stand from floor; walked with frame through to bedroom, client very unsteady on his feet, when settled in bed client complained of pain in his back came over hot and sweaty and breathing changed, night warden called paramedics to attend, left client with paramedics and night warden, left property 00.35. day, they they they
Summary In light of these findings it does not seem that additional training in first aid for Portsmouth Council Housing sheltered housing staff teams is required: The training have is tailored to their role and responsibilities. The Night Responder Team who did attend to Mr Jones do have the appropriate training to lift Mr Jones and are first aid trained: Please do not hesitate to contact me should you require any future information
Sent To
- Portsmouth City Council
Response Status
Linked responses
1 of 1
56-Day Deadline
24 Apr 2018
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 12/05/2017 I commenced an investigation into the death of Ronald Frank JONES aged 88. The investigation concluded at the end of the inquest on 21/11/2017. The conclusion of the inquest was: Mr JONES medical cause of death was 1a Bronchopneumonia, 1b Congestive Cardiac Failure, 1c Cardiac Hypertrophy and Amyloidosis, II Fractured Ribs, Chronic Kidney Disease, Diabetes Mellitus and Frailty of Old Age. My Conclusion was Narrative Conclusion: Ronald Frank JONES died as a result of the processes of natural disease accelerated and significantly contributed to by a fall he sustained in his home on 25 January 2017.
Circumstances of the Death
On 25th January 2017 Mr JONES, a resident of sheltered housing at Arthur Dann Court, Portsmouth, fell in his bathroom. He was found by a Night Support Assistant and subsequently moved to his bed by a Night Responder. He was admitted to Hospital the next day where he died on 4th February 2017.
Action Should Be Taken
Coroner for Portsmouth and South East Hampshire Coroner’s Court, 1 Guildhall Square, Portsmouth, PO1 2GJ Tel: 023 9268 8326 or email: coroners.office@portsmouthcc.gov.uk
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.