Michael Bingham
PFD Report
Partially Responded
Ref: 2017-0322
Coroner's Concerns (AI summary)
Harbour Healthcare failed to implement alarms for insecure internal doors, highlighting a risk assessment "blind spot." The CQC must review regulations and inspection procedures for door safety, and Stockport NHS guidelines lack clarity on CT scan requirements.
View full coroner's concerns
The fall being being have put 1c)
: _ Harbour Healthcare: The evidence that heard was that it Is your responsibility as the Registered Person under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 to comply with those Regulations_ understand that at present; the Guidance issued by the CQC in respect of those provisions (the Guidance on Providers to meeting the Regulations) does not stipulate how you must comply but does advise that any security provisions must make sure that people are safe whilst receiving care and that premises must be fit for purpose in line with statutory requirements. It was accepted by you during the inquest that there was a 'blind spot' in the risk assessment of the internal secure doors, in that you were not required by ay regulatory body to have an alarm to alert staff when secure doors became insecure by virtue of the use of the emergency door release or otherwise_ accept that you have now implemented a alarm system in Hilltop Court Care home that will indicate when the internal doors become insecure and have fitted auditory alarms in relation to the external doors. You indicated that you are in the process of implementing similar systems in the other care homes owned by Harbour Healthcare_ am concerned that without the implementation of these alarms across your service provision there would continue to be circumstances that create a risk of other deaths_ would be grateful for an indication of when you expect this implementation t0 be completed by way of response. CQC: The evidence that heard was that under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 it is the Registered Persons responsibility to comply with those Regulations. understand that at present; the Guidance issued by the CQC in respect of those provisions (the Guidance on Providers to meeting the Regulations) does not stipulate they must comply with those Regulations but does advise that any security provisions must make sure that people are safe whilst receiving care and that premises must be fit for purpose in line with statutory requirements_ accept that on the present Regulations it is for the Registered Person t0 make a risk assessment in relation to internal secure doors and the safety and security that they provide to service users. However, ask you t0 review, in light of the evidence have received in the course of this investigation whether there should be a further issue of regulations or guidance to ensure a consistent approach in respect of the assessment of any safety risk due t0 falls posed by the use of an emergency door release panel. also ask you to review your inspection procedures in respect of a Registered Person's compliance with the Regulations in respect of the safety and security of internal secure doors. Stockport NHS Foundation Trust: am concerned that the current Guidelines for HeadIneck injuries (as amended) may continue t0 provide a lack of clarity as to when CT scans should be considered in those over 65 and with dementia or other cognitive impairment: The word 'confusion' remains under the general guidance (bullet point 5) but has been changed to 'dementia' under the guidance for those who are already subject to a head scan: ask that YOU consider reviewing your guidelines to ensure clarity and consistency of their clinical application: green how being
: _ Harbour Healthcare: The evidence that heard was that it Is your responsibility as the Registered Person under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 to comply with those Regulations_ understand that at present; the Guidance issued by the CQC in respect of those provisions (the Guidance on Providers to meeting the Regulations) does not stipulate how you must comply but does advise that any security provisions must make sure that people are safe whilst receiving care and that premises must be fit for purpose in line with statutory requirements. It was accepted by you during the inquest that there was a 'blind spot' in the risk assessment of the internal secure doors, in that you were not required by ay regulatory body to have an alarm to alert staff when secure doors became insecure by virtue of the use of the emergency door release or otherwise_ accept that you have now implemented a alarm system in Hilltop Court Care home that will indicate when the internal doors become insecure and have fitted auditory alarms in relation to the external doors. You indicated that you are in the process of implementing similar systems in the other care homes owned by Harbour Healthcare_ am concerned that without the implementation of these alarms across your service provision there would continue to be circumstances that create a risk of other deaths_ would be grateful for an indication of when you expect this implementation t0 be completed by way of response. CQC: The evidence that heard was that under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 it is the Registered Persons responsibility to comply with those Regulations. understand that at present; the Guidance issued by the CQC in respect of those provisions (the Guidance on Providers to meeting the Regulations) does not stipulate they must comply with those Regulations but does advise that any security provisions must make sure that people are safe whilst receiving care and that premises must be fit for purpose in line with statutory requirements_ accept that on the present Regulations it is for the Registered Person t0 make a risk assessment in relation to internal secure doors and the safety and security that they provide to service users. However, ask you t0 review, in light of the evidence have received in the course of this investigation whether there should be a further issue of regulations or guidance to ensure a consistent approach in respect of the assessment of any safety risk due t0 falls posed by the use of an emergency door release panel. also ask you to review your inspection procedures in respect of a Registered Person's compliance with the Regulations in respect of the safety and security of internal secure doors. Stockport NHS Foundation Trust: am concerned that the current Guidelines for HeadIneck injuries (as amended) may continue t0 provide a lack of clarity as to when CT scans should be considered in those over 65 and with dementia or other cognitive impairment: The word 'confusion' remains under the general guidance (bullet point 5) but has been changed to 'dementia' under the guidance for those who are already subject to a head scan: ask that YOU consider reviewing your guidelines to ensure clarity and consistency of their clinical application: green how being
Responses
Action Taken
Harbour Healthcare has completed work on internal doors at Hilltop Court, installing screech alarms or box panels, and has fitted screech alarms to internal emergency exit doors at other care homes. They have also completed risk assessments and implemented new internal procedures with regular drills. (AI summary)
Harbour Healthcare has completed work on internal doors at Hilltop Court, installing screech alarms or box panels, and has fitted screech alarms to internal emergency exit doors at other care homes. They have also completed risk assessments and implemented new internal procedures with regular drills. (AI summary)
View full response
Dear Ms Monis can confirm, as yoU indicated in your report; that the work to the internal doors at Hilltop Court have been completed, and that either screech alars or box panels have been installed: These mechanisms are also linked to the Internal nurse emergency call system so the staff will be alerted should one of the Internal doors be opened via the emergency release mechanism can confirm that the work to fit screech alarms to all internal emergency exit doors has been completed in all of Harbour Healthcare's other care homes with the exception of Bentley Manor Nursing Home In Crewe; which will be completed by August 31" 2017 can also confirm that risk assessments have been completed on all modifications and that new internal procedures have been implemented to ensure the staff teams are famillar with the new systems ad that regular drills are conducted and recorded to better enable staff to respond appropriately when a screech alarm sounds. Thank vou for your guidance on this matter: Yours sincerely (dlu Andrew Worfiey CEO key
CQC Care Citygate Sorerisaiox Gallowgate Newcastle upon Tyne NEI 4PA Telephone: 03000 616161 Fax: 03000 616171
Date: 20/10/2017 Reference number: 5423/HC Dear HM Coroner, Care Quality Commission ('Commission') Health and Social Care Act 2008 Re: Regulation 28 report in relation to the death of Mr. Michael Bingham am writing in response to the Regulation 28 report which you issued on 31 July 2017 following the inquest into the sad death of Mr. Michael Bingham. The registered provider for Stepping Hill Hospital is Stockport NHS Foundation Trust - At the time of Mr: Bingham's death the trust had active Requirement Notices that had been issued in August 2016 against: Regulation 10 (dignity and respect); Regulation 12 (safe care and treatment); Regulation 14 (meeting nutritional and hydration needs); Regulation 17 (good governance); and Regulation 18 (staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (all further references to Regulations in this letter are to these 2014 Regulations unless specifically stated otherwise) (A Requirement Notice formally notifies a provider that we consider are in breach of legal requirements and should take steps to improve standards:) We undertook an unannounced inspection of Stepping Hill Hospital on 21 and 22 March
2017. copy of the report can be found on our website at: WWCGC org uklsites/defaultlfilesInew_reportsIAAAG7959pdi This inspection was conducted in response to concerns received by the Commission and analysis of intelligence available to uS. This inspection focused on the urgent care service (Emergency Department) and medical services (medical care wards) As part of this inspection we requested documentation pertaining to all serious incidents which had been reported in the Emergency Department for the 12 months they the
prior to our inspection: This information was received in April 2017. When we received this information we then requested the investigation reports for number of the incidents to review in closer detail:. One of these records related to Mr. Bingham: The review of these records took place between April and 2017 . At the time of our inspection and review the investigation report was not finalized and we were made aware by the trust that case was awaiting an inquest The case was specifically discussed by the inspectors undertaking the inspection with the inspection manager ieading the inspection team and the action plan in relation to this incident was reviewed: This action plan was a standard action plan contained at the end of a serious incident review. The action plan contained key actions to reduce the risk of re-occurrences which the trust had identified through their review of the incident. The trust advised that the action plan was to be reviewed on regular basis. The case was then raised as part of our internal management review process for the inspection within which we held several meetings to determine what action should be taken in response to this incident and also the wider issues identified as part of the inspection: At that time it was decided that we would wait for the outcome of the inquest and then hold another management review meeting specifically looking at Mr. Bingham's case. This was in relation to both our civil and criminal prosecution powers: In addition to this and to secure immediate improvement and safety we also decided to take action in response to the concerns we identified the inspection including issues relating to Mr: Bingham's case. This action is summarized below: A risk summit was convened with key stakeholders including NHS England, NHS Improvement; Clinical Commissioning Groups, General Medical Council: Stockport Local Authority and the North West Medical Deanery: This meeting was held on 10 2017 . The outcome of this meeting was that a monthly improvement board would be convened with all key stakeholders and support and improvement package would be in place to scrutinize, monitor and secure improvement in the areas identified during the inspection, namely the Emergency department: further outcome was that the trust would be considered by NHS England and the chief inspector of hospitals to be given 'challenged trust' status_ This status provides the trust with additional support from key agencies including NHS improvement. Shortly after this meeting this status was confirmed and agreed. The trust remains in 'challenged trust' status at the time of writing: Monthly improvement boards have continued and are attended by an inspection manager within the Commission: We found the trust in breach of several regulations and specifically in relation to Mr. Bingham's case in breach of Regulation 12 (safe care and treatment): 2 May the during May put key
In response to this it was decided through our intemal management review process to issue Requirement Notices to the trust on these Regulations including Regulation 12 (safe care and treatment) These Requirement Notices are issued as part of the report publication process and the trust has 28 days in which to submit an action plan for addressing these areas: However in addition we formally wrote to the trust and requested immediate assurance on how they intended to meet the Regulations they were breaching: The trust provided us with a robust action plan which was scrutinised by senior staff within the Commission and also at the monthly improvement board meetings: We undertook follow up unannounced inspection on 22 and 23 June 2017. A copy of the report can be found on our website at the following link: WWW_ cqc.org uklsitesldefaultfilesInew_reportsIAAAG7930.pdf In addition to the improvement board we also increased our engagement frequency with the trust and communicate with them at the very least on weekly basis This is to share intelligence and receive assurance on progress against the concerns we have raised. The decision was also made to directly reference the anonymised incident relating to Mr; Bingham in the inspection report under the effective heading: The incident relating to Mr. Bingham also formed part of our decision making for the rating within the effective domain for urgent' care services. The rating for this domain was downgraded from 'Good' to 'Requires Improvement' . Since we have received the Regulation 28 report relating to Mr; Bingham, we have held two further management review meetings_ These meetings have been attended by our legal team and the Head of Hospital Inspection for the North West. The outcome of these meetings is that we have asked for additional information from the trust and other agencies including Greater Manchester Police to better inform our considerations on the issue of whether we may (if at all) need to take any further action against the trust from civil andlor criminal enforcement perspective. When this is provided we will be holding further internal management review meetings to review the information in line with our Enforcement Policy and our Enforcement Decision Tree to make determinations on the issue of any civil andlor criminal enforcement which may be appropriate. In relation to the specific concerns you raised in your report namely your concerns that the current guidelines for the management of head and neck injury may still be unclear; Based on the information we currently hold we can confirm that the trust has breached Regulation 12(1) (safe care and treatment):
The trust have assured us that are in the process of considering your report and are considering changes to their guidelines in response to this We would expect the trust to review these guidelines as part of their response to your report and we will be receiving copy of their response. When we receive their response we will review the action the trust has taken in response to your report: This will then fomm part of the discussion and decision-making in line with our internal processes and specifically in relation to the issue of whether further regulatory action may be warranted: As outlined above we have issued the trust with a Requirement Notice for Regulation 12(1): The trust has submitted an action plan in response to this and we have accepted this action plan: This action plan and progress against the actions contained in the plan will be monitored the through the monthly quality board meetings and our routine engagement meetings: To be clear however the existing guidelines meet National Institute for Health and Care Excellence guidance but contains an additional chart: During our inspection We identified a risk that staff were not following guidelines and the trust has received Requirement Notice in that regard: We consider the trust's action plan to be robust which in turn mitigates the identified risk This is monitored by the Commission, NHSI and NHSE through a monthly quality meeting: We are assured that any risk is appropriately mitigated through the steps outlined above and the additional work with NHS Improvement and NHS England ensures that the trust is subject to additional scrutiny: Yours sincerely Head of Hospitals Inspection North West they being
CQC Care Citygate Coreissiov Gallowgate Newcastle upon Tyne NE1 4PA Telephone: 03000 616161 Fax: 03000 616171 WWW,cqC org:uk Date: 20/10/2017 Reference number: 5423/HC HM Coroner Care Quality Commission ('CQC') Health and Social Care Act 2008 Re: Regulation 28 report in relation to the death of Mr: Michael Bingham Thank you for the Regulation 28 Report following the Inquest touching on the sad death of Mr Michael Bingham: Colleagues in our Adult Social Care Inspection team are responding separately to your Report and the matters of concern which come directly within their remit This response relates specifically to the following points raised in your report: CQC: The evidence thal heard was Ihat under Ihe Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 it is lhe Registered Persons responsibility lo comply wilh those Regulations: understand that at presenl; the Guidance issued by Ihe CQC in respect of those provisions (Ihe Guidance on Providers to meeting lhe Regulations) does nol stipulale they must comply with Ihose Regulations bul does advise thal any security provisions must make sure thal people are safe whilst receiving care and that premises must be fit for purpose in Iine with statulory requlrements accept thal on Ihe presenl Regulations it is for the Regislered Person lo make a risk assessmenl in relalion (o inlernal secure doars and (he safety and security Ihat provide lo service users However, ask you to review, in light of the evidence have received In Ihe course of thls Investigatlon whelher there should be a further issue of regulations or guidance lo ensure a consistent approach in respect of Ihe assessment of any safety risk due to falls posed by Ihe use of an emergency door release panel. also ask you to review your inspection procedures in respect of a Regislered Person's compliance with the Regulations in respect of Ihe safely and securily of internal secure doors: Dear how they
Further _issue of Regulations andlor Guidance CQC proposing the amendment of the regulations is unlikely to be the most timely and effective mechanism for change or improvement in this area: The issue at hand is highly technical and specific; regulations are usually set at a higher level, with detailed risks and issues addressed through codes and practice and guidance: In addition, door release mechanisms have not so far been identified as a key safety issue through multiple incidents similar to those involved in this incident; it is very unlikely, despite this latest tragedy, to be seen as a priority for specific legislative change at this time_ The CQC website already signposts the relevant Health and Safety Executive (HSE) guidance (Health and safety in care homes (2014)- HSG 220) alongside our own guidance to providers on how they can meet the regulations: We have contacted the HSE t0 check that we are still signposting to the most current guidance from them in relation to secure doors and in care homes. They have responded to say that have no current plans for revising the guidance referred to in the previous paragraph: The earliest that they would review it would be in the next financial year 2018/19. We will continue to signpost the most up to date information and guidance available to providers who are registered with CQC. Review of Inspection procedures Premises safety foms part of the assessment we make of care home providers when we ask our key question 'Is the service safe?' There is a Line of Enquiry in our inspection assessment framework that asks: How are risks to people assessed and their safety monitored and managed so they are supported to stay safe and their freedom is respected? Inspectors explore how premises and the safety of communal and personal spaces are checked and managed to support people to stay safe when following this line of enquiry: As noted in your report; neither the regulations nor our assessment frameworks are prescriptive on how providers who are registered with uS should do this. This is because each service is different and the needs of the people they care for and support can and do vary substantially: Providers must necessarily assess risks in different ways and focus on different issues in a proportionate way at all times taking into account the individual circumstances of their particular service as well as the people who use it However, we do recognise that there are lessons to be learnt from this sad death. We always consider and learn from Regulation 28 reports and their recommendations in our Regional Regulatory Risk Meetings Within that forum we will explore how we can better inform our inspectors about the risks and issues identified as a result of this incident; and discuss how best to do so in our internal Continuous Improvement, Quality and Evaluation Group. We will also consider whether associated changes are needed when we begin planned work on the next iteration of our assessment framework, which is due to commence later this We will also explore how can inform a planned checklist for use by inspectors when inspecting the safety of care homes premises: In doing all of this we must however have regard to the fact that as with most regulators (and in accordance with our regulatory remit) CQC highlights breaches of the regulations to a Provider and requires compliance, but does not tell them how gates they Key they year: they
must do sO. That is for the Provider andlor Registered Manager t0 decide. It would not be appropriate for CQC to direct or micro-manage the day to day work of Providers. Please do not hesitate to get in touch if you have any further questions. We will be happy to assist Yours Sincerely, Dauid Jamec (signature typed;, 20/10/2017) Head of Adult Social Care Policy Care Quality Commission Email 3
Coreisalor HSCA Further Information Citygate Gallowgate Newcastle upon Tyne NE1 4PA Telephone: 03000 616161 HM Coroner Fax: 03000 616171 Manchester South Coroner's Court Mount Tabor Street Stockport SK1 3AG 3 October 2017 Care Quality Commission (CQC) Our Reference: MRRI 3574600002 Dear HM Coroner Prevention of future death report following inquest into the death of Michael BINGHAM Thank you for sending CQC a copy of the prevention of future death report (Regulation 28) issued following the death of Mr Bingham: As you are aware the CQC Inspection Team attended the Inquest and were represented by Mr Harrison of Counsel: For that reason we won"t repeat here the content of the letter(s) which were submitted on our behalf by the CQC Legal Team in advance of the Inquest The registered provider Harbour Healthcare has copied CQC into correspondence sent to yourself confirming the action have taken following the death of Mr Bingham and the additional action they have taken in response to your Regulation 28 Report: We will be undertaking a further inspection of the service over the coming weeks to verify that screech alarms or key box panels have been installed t0 internal doors at Hilltop Court Nursing Home, as detailed in the registered provider's response to the Regulation 28 Report: The registered provider has advised that all other Harbour Healthcare's care homes have been fitted with screech alarms_ This will be verified by CQC at the next inspections of each of their locations. they
Following the Inquest we also held an internal review of the facts in relation to Mr Bingham's fall at the care home and concluded that there was no evidence to indicate that a regulatory breach on the part of the Registered Provider andlor Registered Manager had occurred which had then led to Mr Bingham's fall: Should you require any further information then please do not hesitate to get in touch:
CQC Care Citygate Sorerisaiox Gallowgate Newcastle upon Tyne NEI 4PA Telephone: 03000 616161 Fax: 03000 616171
Date: 20/10/2017 Reference number: 5423/HC Dear HM Coroner, Care Quality Commission ('Commission') Health and Social Care Act 2008 Re: Regulation 28 report in relation to the death of Mr. Michael Bingham am writing in response to the Regulation 28 report which you issued on 31 July 2017 following the inquest into the sad death of Mr. Michael Bingham. The registered provider for Stepping Hill Hospital is Stockport NHS Foundation Trust - At the time of Mr: Bingham's death the trust had active Requirement Notices that had been issued in August 2016 against: Regulation 10 (dignity and respect); Regulation 12 (safe care and treatment); Regulation 14 (meeting nutritional and hydration needs); Regulation 17 (good governance); and Regulation 18 (staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (all further references to Regulations in this letter are to these 2014 Regulations unless specifically stated otherwise) (A Requirement Notice formally notifies a provider that we consider are in breach of legal requirements and should take steps to improve standards:) We undertook an unannounced inspection of Stepping Hill Hospital on 21 and 22 March
2017. copy of the report can be found on our website at: WWCGC org uklsites/defaultlfilesInew_reportsIAAAG7959pdi This inspection was conducted in response to concerns received by the Commission and analysis of intelligence available to uS. This inspection focused on the urgent care service (Emergency Department) and medical services (medical care wards) As part of this inspection we requested documentation pertaining to all serious incidents which had been reported in the Emergency Department for the 12 months they the
prior to our inspection: This information was received in April 2017. When we received this information we then requested the investigation reports for number of the incidents to review in closer detail:. One of these records related to Mr. Bingham: The review of these records took place between April and 2017 . At the time of our inspection and review the investigation report was not finalized and we were made aware by the trust that case was awaiting an inquest The case was specifically discussed by the inspectors undertaking the inspection with the inspection manager ieading the inspection team and the action plan in relation to this incident was reviewed: This action plan was a standard action plan contained at the end of a serious incident review. The action plan contained key actions to reduce the risk of re-occurrences which the trust had identified through their review of the incident. The trust advised that the action plan was to be reviewed on regular basis. The case was then raised as part of our internal management review process for the inspection within which we held several meetings to determine what action should be taken in response to this incident and also the wider issues identified as part of the inspection: At that time it was decided that we would wait for the outcome of the inquest and then hold another management review meeting specifically looking at Mr. Bingham's case. This was in relation to both our civil and criminal prosecution powers: In addition to this and to secure immediate improvement and safety we also decided to take action in response to the concerns we identified the inspection including issues relating to Mr: Bingham's case. This action is summarized below: A risk summit was convened with key stakeholders including NHS England, NHS Improvement; Clinical Commissioning Groups, General Medical Council: Stockport Local Authority and the North West Medical Deanery: This meeting was held on 10 2017 . The outcome of this meeting was that a monthly improvement board would be convened with all key stakeholders and support and improvement package would be in place to scrutinize, monitor and secure improvement in the areas identified during the inspection, namely the Emergency department: further outcome was that the trust would be considered by NHS England and the chief inspector of hospitals to be given 'challenged trust' status_ This status provides the trust with additional support from key agencies including NHS improvement. Shortly after this meeting this status was confirmed and agreed. The trust remains in 'challenged trust' status at the time of writing: Monthly improvement boards have continued and are attended by an inspection manager within the Commission: We found the trust in breach of several regulations and specifically in relation to Mr. Bingham's case in breach of Regulation 12 (safe care and treatment): 2 May the during May put key
In response to this it was decided through our intemal management review process to issue Requirement Notices to the trust on these Regulations including Regulation 12 (safe care and treatment) These Requirement Notices are issued as part of the report publication process and the trust has 28 days in which to submit an action plan for addressing these areas: However in addition we formally wrote to the trust and requested immediate assurance on how they intended to meet the Regulations they were breaching: The trust provided us with a robust action plan which was scrutinised by senior staff within the Commission and also at the monthly improvement board meetings: We undertook follow up unannounced inspection on 22 and 23 June 2017. A copy of the report can be found on our website at the following link: WWW_ cqc.org uklsitesldefaultfilesInew_reportsIAAAG7930.pdf In addition to the improvement board we also increased our engagement frequency with the trust and communicate with them at the very least on weekly basis This is to share intelligence and receive assurance on progress against the concerns we have raised. The decision was also made to directly reference the anonymised incident relating to Mr; Bingham in the inspection report under the effective heading: The incident relating to Mr. Bingham also formed part of our decision making for the rating within the effective domain for urgent' care services. The rating for this domain was downgraded from 'Good' to 'Requires Improvement' . Since we have received the Regulation 28 report relating to Mr; Bingham, we have held two further management review meetings_ These meetings have been attended by our legal team and the Head of Hospital Inspection for the North West. The outcome of these meetings is that we have asked for additional information from the trust and other agencies including Greater Manchester Police to better inform our considerations on the issue of whether we may (if at all) need to take any further action against the trust from civil andlor criminal enforcement perspective. When this is provided we will be holding further internal management review meetings to review the information in line with our Enforcement Policy and our Enforcement Decision Tree to make determinations on the issue of any civil andlor criminal enforcement which may be appropriate. In relation to the specific concerns you raised in your report namely your concerns that the current guidelines for the management of head and neck injury may still be unclear; Based on the information we currently hold we can confirm that the trust has breached Regulation 12(1) (safe care and treatment):
The trust have assured us that are in the process of considering your report and are considering changes to their guidelines in response to this We would expect the trust to review these guidelines as part of their response to your report and we will be receiving copy of their response. When we receive their response we will review the action the trust has taken in response to your report: This will then fomm part of the discussion and decision-making in line with our internal processes and specifically in relation to the issue of whether further regulatory action may be warranted: As outlined above we have issued the trust with a Requirement Notice for Regulation 12(1): The trust has submitted an action plan in response to this and we have accepted this action plan: This action plan and progress against the actions contained in the plan will be monitored the through the monthly quality board meetings and our routine engagement meetings: To be clear however the existing guidelines meet National Institute for Health and Care Excellence guidance but contains an additional chart: During our inspection We identified a risk that staff were not following guidelines and the trust has received Requirement Notice in that regard: We consider the trust's action plan to be robust which in turn mitigates the identified risk This is monitored by the Commission, NHSI and NHSE through a monthly quality meeting: We are assured that any risk is appropriately mitigated through the steps outlined above and the additional work with NHS Improvement and NHS England ensures that the trust is subject to additional scrutiny: Yours sincerely Head of Hospitals Inspection North West they being
CQC Care Citygate Coreissiov Gallowgate Newcastle upon Tyne NE1 4PA Telephone: 03000 616161 Fax: 03000 616171 WWW,cqC org:uk Date: 20/10/2017 Reference number: 5423/HC HM Coroner Care Quality Commission ('CQC') Health and Social Care Act 2008 Re: Regulation 28 report in relation to the death of Mr: Michael Bingham Thank you for the Regulation 28 Report following the Inquest touching on the sad death of Mr Michael Bingham: Colleagues in our Adult Social Care Inspection team are responding separately to your Report and the matters of concern which come directly within their remit This response relates specifically to the following points raised in your report: CQC: The evidence thal heard was Ihat under Ihe Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 it is lhe Registered Persons responsibility lo comply wilh those Regulations: understand that at presenl; the Guidance issued by Ihe CQC in respect of those provisions (Ihe Guidance on Providers to meeting lhe Regulations) does nol stipulale they must comply with Ihose Regulations bul does advise thal any security provisions must make sure thal people are safe whilst receiving care and that premises must be fit for purpose in Iine with statulory requlrements accept thal on Ihe presenl Regulations it is for the Regislered Person lo make a risk assessmenl in relalion (o inlernal secure doars and (he safety and security Ihat provide lo service users However, ask you to review, in light of the evidence have received In Ihe course of thls Investigatlon whelher there should be a further issue of regulations or guidance lo ensure a consistent approach in respect of Ihe assessment of any safety risk due to falls posed by Ihe use of an emergency door release panel. also ask you to review your inspection procedures in respect of a Regislered Person's compliance with the Regulations in respect of Ihe safely and securily of internal secure doors: Dear how they
Further _issue of Regulations andlor Guidance CQC proposing the amendment of the regulations is unlikely to be the most timely and effective mechanism for change or improvement in this area: The issue at hand is highly technical and specific; regulations are usually set at a higher level, with detailed risks and issues addressed through codes and practice and guidance: In addition, door release mechanisms have not so far been identified as a key safety issue through multiple incidents similar to those involved in this incident; it is very unlikely, despite this latest tragedy, to be seen as a priority for specific legislative change at this time_ The CQC website already signposts the relevant Health and Safety Executive (HSE) guidance (Health and safety in care homes (2014)- HSG 220) alongside our own guidance to providers on how they can meet the regulations: We have contacted the HSE t0 check that we are still signposting to the most current guidance from them in relation to secure doors and in care homes. They have responded to say that have no current plans for revising the guidance referred to in the previous paragraph: The earliest that they would review it would be in the next financial year 2018/19. We will continue to signpost the most up to date information and guidance available to providers who are registered with CQC. Review of Inspection procedures Premises safety foms part of the assessment we make of care home providers when we ask our key question 'Is the service safe?' There is a Line of Enquiry in our inspection assessment framework that asks: How are risks to people assessed and their safety monitored and managed so they are supported to stay safe and their freedom is respected? Inspectors explore how premises and the safety of communal and personal spaces are checked and managed to support people to stay safe when following this line of enquiry: As noted in your report; neither the regulations nor our assessment frameworks are prescriptive on how providers who are registered with uS should do this. This is because each service is different and the needs of the people they care for and support can and do vary substantially: Providers must necessarily assess risks in different ways and focus on different issues in a proportionate way at all times taking into account the individual circumstances of their particular service as well as the people who use it However, we do recognise that there are lessons to be learnt from this sad death. We always consider and learn from Regulation 28 reports and their recommendations in our Regional Regulatory Risk Meetings Within that forum we will explore how we can better inform our inspectors about the risks and issues identified as a result of this incident; and discuss how best to do so in our internal Continuous Improvement, Quality and Evaluation Group. We will also consider whether associated changes are needed when we begin planned work on the next iteration of our assessment framework, which is due to commence later this We will also explore how can inform a planned checklist for use by inspectors when inspecting the safety of care homes premises: In doing all of this we must however have regard to the fact that as with most regulators (and in accordance with our regulatory remit) CQC highlights breaches of the regulations to a Provider and requires compliance, but does not tell them how gates they Key they year: they
must do sO. That is for the Provider andlor Registered Manager t0 decide. It would not be appropriate for CQC to direct or micro-manage the day to day work of Providers. Please do not hesitate to get in touch if you have any further questions. We will be happy to assist Yours Sincerely, Dauid Jamec (signature typed;, 20/10/2017) Head of Adult Social Care Policy Care Quality Commission Email 3
Coreisalor HSCA Further Information Citygate Gallowgate Newcastle upon Tyne NE1 4PA Telephone: 03000 616161 HM Coroner Fax: 03000 616171 Manchester South Coroner's Court Mount Tabor Street Stockport SK1 3AG 3 October 2017 Care Quality Commission (CQC) Our Reference: MRRI 3574600002 Dear HM Coroner Prevention of future death report following inquest into the death of Michael BINGHAM Thank you for sending CQC a copy of the prevention of future death report (Regulation 28) issued following the death of Mr Bingham: As you are aware the CQC Inspection Team attended the Inquest and were represented by Mr Harrison of Counsel: For that reason we won"t repeat here the content of the letter(s) which were submitted on our behalf by the CQC Legal Team in advance of the Inquest The registered provider Harbour Healthcare has copied CQC into correspondence sent to yourself confirming the action have taken following the death of Mr Bingham and the additional action they have taken in response to your Regulation 28 Report: We will be undertaking a further inspection of the service over the coming weeks to verify that screech alarms or key box panels have been installed t0 internal doors at Hilltop Court Nursing Home, as detailed in the registered provider's response to the Regulation 28 Report: The registered provider has advised that all other Harbour Healthcare's care homes have been fitted with screech alarms_ This will be verified by CQC at the next inspections of each of their locations. they
Following the Inquest we also held an internal review of the facts in relation to Mr Bingham's fall at the care home and concluded that there was no evidence to indicate that a regulatory breach on the part of the Registered Provider andlor Registered Manager had occurred which had then led to Mr Bingham's fall: Should you require any further information then please do not hesitate to get in touch:
Sent To
- Care Quality Commission
- Harbour Healthcare
- Stockport NHS Trust
Response Status
Linked responses
1 of 3
56-Day Deadline
25 Sep 2017
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 31/10/2016 commenced an investigation into the death of Michael Bingham_ investigation concluded at the end of the inquest 26th July 2017. The conclusion of the inquest was On the 22nd September 2016 the deceased exited through an internal door on the first floor Hilltop Court Care home and fell down stairs His was as a direct result of the emergency door release activated, which caused all the internal secure doors within the home t0 release. find that the fact that the home staff had no way of knowing that the emergency door release had been activated or which doors were insecure also contributed to his ability to exit through the door and therefore to his fall. As a result of his fall, the suslained a fracture to his C1ICZ vertebrae. On attendance at Stepping Hill Hospital on the 22nd September 2016, the Emergency Department Guidelines required that consideration be given to subjecting those over 65 with a suspected head injury a CT scan_ On clinical examination, the Doctor decided not to order a CT scan. As a result of a scan not done on this date, the fracture on the CT1/ CT2 vertebrae was not diagnosed and he was returned to (he care home Had the fracture been identified on the 22nd September the deceased would more likely than not remained in hospital, been fitted with an orthopaedic collar and intensively nursed in a manner that would have sought to reduce his risk of contracting infection due to immobility or positioning: find on the balance of probabilities that the fact that the deceased had undiagnosed fracture impacted on his spinal cord and affected his respiration and ability t0 swallow; which caused him to aspire matter on or after the 23rd September, which then caused pneumonia to develop. On re-admission to Stepping Hill Hospital on the 24th September 2016 his pneumonia had advanced to the degree that when he was examined at 17.50 he had strident breathing and he had become unresponsive. End of life care was place and death was confirmed at 20.15. 1a) Aspiration pneumonia Ib) Fracture of C1IC2 vertebrae Fall
2) Vascular Dementia Coronary artery atheroma
2) Vascular Dementia Coronary artery atheroma
Circumstances of the Death
See above
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.