Kathleen Smith
PFD Report
All Responded
Ref: 2017-0397
All 1 response received
· Deadline: 12 Apr 2018
Coroner's Concerns (AI summary)
The care home failed to notify the family and corporate risk of a resident's injury, preventing proper investigation and learning. Incident reporting relied on a single, departed manager, with no audit or review since, despite missing documentation.
View full coroner's concerns
_ In the course of the inquest heard evidence that; whilst the management team at Lisburne Court had notified Greater Manchester Police and Stockport Metropolitan Borough Council of the incident in which Mrs Smith sustained on April 2017, neither the family nor Borough Care'$ corporate risk function had been notified of the circumstances which led to Mrs Smith's hip fracture This latter point raises a particular concern a5 to Borough Care'5 ability to undertake any meaningful investigation into the circumstances of Mrs Smith'$ injury, with a view to deriving learning for the benefit of other residents. The inquest also heard evidence that Lisburne Court's process for internal incident reporting and escalation largely fell to an individual manager who has since left Borough Care'$ employment: It was a matter of concern that notwithstanding this fact, no audit or similar review exercise as to incidents or issues at Lisburne Court had been undertaken since the departure of the individual manager in question, despite the evidence of the Interim Head of Care that some resident documentation and computer files has allegedly gone missing:
Responses
Action Taken
Borough Care has introduced a weekly form for managers to report significant incidents to the Head of Care, discussed in weekly Care & Quality meetings, with Area Support follow-up. (AI summary)
Borough Care has introduced a weekly form for managers to report significant incidents to the Head of Care, discussed in weekly Care & Quality meetings, with Area Support follow-up. (AI summary)
View full response
Dear Mr Morris Thank you for your correspondence of 14th November regarding the Death of Kathleen Smith: Following the Inquest; have taken on board your comments regarding head office not aware of incidents that happen in the individual care homes within Borough Care Ltd. Borough Care Ltd do expect our Managers to keep us informed of events that happen in the home: However; on this occasion the manager did not inform the Head of regarding the fall that Mrs Smith had or the injury that was incurred: This should have happened as a matter of procedure. therefor devised a form that managers must complete on weekly basis to inform Head of Care of any significant incidents that happen in the home: These incidents are discussed weekly at our Care & Quality meetings and any follow up is actioned by the Area Support for that Home: This form was introduced to all Managers on the 26th October at our monthly Managers meeting and was actioned by the Managers from the following Monday: Our Quality Manager and Area support team also ensure that any incidents are discussed on their audit meetings with the Home Manager: It is unfortunate that the Manager of Lisbume Court at that time did not follow procedure and as discussed in Court the Manager left the service, however if she hadn't left the service her capability to manager was under scrutiny and action would have been taken: have enclosed two copies of the form completed weekly by the ManagerIDeputy Manager: INVESTORS Silver Bcrough Care Limiled is an Induslrlal end Frovident Sociely wilh charitable $alys; IN PEOPLE Registered Ofica: Acorn Business Park; Haaton Lana Stockpont Sk4 JAS Reg stered number 277883 being Care have will
Part of a Series
2 separate reports were issued from this inquest, each sent to different organisations.
-
2019-0184
Sent to: Coed Duon Care HomeAll responded
This report (2017-0397) is shown above.
Sent To
- Borough Care
Response Status
Linked responses
1 of 1
56-Day Deadline
12 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 13th June 2017, Chris Murray, Assistant Coroner for Manchester South, opened an inquest into the death of Kathleen Smith who was aged 80 when she died at her care home on 4th June 2017_ The investigation concluded at the end of the inquest which heard on 20th October 2017. The conclusion of the inquest was that Mrs Smith died as a result of a stroke whilst being in the advanced stages of dementia. Whilst this is a natural cause of death, the inquest concluded her death was contributed to by a hip fracture sustained on 12th April 2017at her care home when she fell to the floor having been pushed by another resident: At the end of the inquest, recorded a Narrative Conclusion to this effect_
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.