REPORT FOLLOWING REGULATION 28: REPORT TO PREVENT FUTURE DEATHS 1 CORONER Brown LLM H M Senior Coroner North Northumberland 2 CLIENT Jack Basil Lynn 3 MATTERS OF CONCERN RAISED BY SENIOR CORONER Arrangements put in place for prompting with medication did not include keeping a medication communication sheet at Mr Lynn's home address as a continuous record of his medications, This would have allowed for a more reliable check by visiting carers or family members as it would have clearly indicated whether medications were being taken regularly. The absence of any check on Mr Lynn's safety or well being during the allocated 15 minute visit on the morning of 15t October 2013 exposed Mr Lynn to potential risk, albeit that the sudden cardiac event which occurred could not have been prevented, The risk was present, nonetheless, and creates a risk that future deaths might occur if action is not taken. ACTION TAKEN FOLLOWING INCIDENT We will encourage all of our clients to have medication charts in their communication folder and in the case of not wishing to have one we will advise that if a carer is involved in any service concerning medication it is Company policy to have them in the folder. We have advised all staff to make themselves re-aware of our medication policy in their handbook and to actively ask any questions that arise We have had an Independent Trainer provide Safe Handling of Medication course in October 2013 to which twenty two staff attended_
5. ACTION TAKEN TO EMPLOYEE INVOLVED IN INCIDENT The staff member was given a verbal warning in disciplinary meeting for not following Company procedure in not physically checking her client and his medication prompt and advised that in the future she should always physically check on a client unless we, Management; have their written word not to and a set procedure is detailed for the individual client to carry out our service to their wishes 6 DATE February 2014. DIRECTOR OF NIGHTINGALES HOME HELP SERVICE E0 jovd T6sE0E6831D LZ:0T pioz/E0/80 Tony daily 27th