UK Inquiry Tracker

Joyce Crompton

PFD Report All Responded Ref: 2016-0434

Date of Report 6 December 2016

Coroner Rachael Griffin

Coroner Area Manchester (West)

Response Deadline est. 9 April 2017

Care Home Health related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 9 Apr 2017

Coroner's Concerns (AI summary)

The care home lacked written policies, systematic checklists, and refresher training for Speech and Language Therapy (SALT) referrals, leading to missed assessments for residents after choking incidents.

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During the inquest evidence was heard that: When a resident at Belong Village chokes there should always be a referral to the SALT team to assess their swallowing: A is sent by the home to the GP who then will submit a referral to the SALT team: Once the fax has been sent to the home the staff will chase up the referral by telephone: If a referral is done it will be recorded in the GP healthcare visits section of the resident's notes: iis There is no written policy or procedure in place and staff are given verbal advice on referrals to outside agencies, such as SALT , when start working at the home; There is no systematic checklist to complete to ensure a referral has been done or to confirm when the referral has been chased, iii, After the witnessed choking incident Mrs Crompton experienced at Belong Village on the 14 September 2015 a referral was not sent to the GP or to SALT. iv After the witnessed choking incident Crompton experienced on the 10th December 2015 at Belong Village; a referral was not made to the GP or to SALT. It was recorded in the notes and the home diary that a referral to SALT was to be done, but none of the staff did the referral; The staff who gave evidence at the Inquest all confirmed that had presumed that it had been done, however there was no record on the GP Healthcare visits sheet that a referral had been done I have concerns with regard to the following: It is clear that although there is verbal training given on referrals to outside agencies, such as SALT, there is no written guidance that can be easily referred to when incidents arise, There is also no refresher training on the policies Due to this there may be another occasion in the future when a referral to the SALT team is missed which could result in a future death_ ii I therefore request that a review is undertaken of the policies, procedures ad training in place at Belong Village in relation to referrals to the SALT team to avoid future referrals missed. fax they Mrs they being

ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and believe you andJor your organisation have the power to take such action: YOUR RESPONSE You are under a duty to respond to this report within 56 days of date of this report; 31st January 2017_ L, the coroner , may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action: Otherwise you must explain why no action is proposed. COPIES and PUBLICATION I have sent a COpy of my report to the Chief Coroner and to the following Interested Persons: (1) Mrs Crompton's son on behalf of the family
2) Hill Dickinson LLP on behalf of the Speech and Language Therapy team (3) The Care Quality Commission, North Region Iam also under a duty to send the Chief Coroner a copy of your response I have also sent a copy to Wigan Borough Clinical Commissioning Group, Wigan Life Centre, College Avenue; Wigan, WNI 1NJ. The Chief Coroner may publish either or both in complete or redacted or summary form; He may send a copy of this report to any person who he believes may find it useful or of interest: You may make representations to me; the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner Dated Signed 6th December 2016 Rachael C Griffin E+ttus the

Responses

Belong

15 Dec 2016

Action Taken
Belong has reminded managers and nurses of policy adherence, requested reassessment of residents' choking risk, updated staff training, and will review policies in a meeting with registered managers. Staff at Belong Atherton have received updated training about Dysphagia which will be cascaded throughout the organization. (AI summary)

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Dear Ms Griffin Joyce Crompton Deceased acknowledge receipt of your letter dated 6 December 2016 and the Regulation 28 and 29 report to prevent future deaths_ acknowledge that the conclusion of the Inquest was choking on regurgitated food with the underlying cause of Vascular Dementia. note the Coroner's matters of concerns and would Iike to provide you with my response: No written Guidance regarding referrals to outside agencies such as SALT can confirm that Belong does have a set of Policies and Procedures that provides clear guidelines for staff about when to refer to other professionals. policy 'Nutrition and Hydration' provides staff with clear guidelines about when to refer individuals to the Speech and Language Therapist (SALT) The policy states that: "advice should always be sought to assist staff with swallowing strategies and appropriate positioning and to minimise the risk of aspiration or choking for the person with an unsafe swallow" The guidance also references a flow chart in Appendix that provides information about 'When to refer to the Speech and Language Therapy team for Dysphagia'. In addition to this guidance we have the following documentation: is part of CLS Care Services Limited, a Registered Society under the Co-Operative and Communities Benefit Societies Act 2014, registered number 27346R. Registered in England & Wales at Pepper House, Market Street; Nantwich, Cheshire CWS 50Q, INVESTORS IN PEOPLE Your Our Belong

Marvellous Mealtimes policy section 15 'Swallowing Difficulties' Refer for a swallowing assessment and advice from the Speech and Language Therapist SALT): MUST Assessment for the risk of Malnutrition 'A person who has swallowing problems notify GP; ask for referral to speech and language therapist Document on care plan'. Daily Food Intake records all reference the national descriptors of food type that has been prescribed. Life Plan Food and Drink a section for 'These are the difficulties that have' to be documented_ Care Practice Guidelines Food and Drink acknowledge that whilst we have the necessary Policies, Procedures Guidelines and documentation in place staff have failed to refer to them when caring for this lady and have failed to seek external advice from healthcare professionals and to document any changes can confirm that the following actions have taken place: AlI Belong Managers and Nurses have been reminded of the importance of following the Organisation's policies and procedures and reminded to raise awareness with their staff teams Staff have been requested to reassess all residents risk of choking and ensure follow up referral are made to SALTs with immediate effect. meeting is held on Wednesday, 21 December with all Belong Registered Managers to review the Policies, Procedures and Guidance and discuss how we can be more effect in our delivery of safe care_ Staff at Belong Atherton have received update training about Dysphagia and this will be cascaded throughout the organisation: The Learning and Development team will review induction procedures and resources for 'learning will be evaluated;, as will frequency of updates. All Support Workers have been reminded of the correct procedures to follow and how to seek advice from outside professionals and when they need to escalate health concerns. This is incorporated into the care practice training for all staff; to include staff induction, supervision, life plan review and audit trust that my response will provide you with the reassurance that we have reviewed and communicated our procedures following the Coroners concerns over the death of Joyce Crompton, and therefore improved the safety of our practice.