Stanley Dobson
PFD Report
Partially Responded
Ref: 2013-0303
Coroner's Concerns (AI summary)
Locum doctors failed to report patient non-response to the operative, hindering further contact efforts. Protocols need extending to ensure non-responses are consistently reported.
View full coroner's concerns
During the course of the inquest the evidence revealed a matter that gave rise to concern and which, in my opinion, there is a risk that future deaths could occur by reason thereof unless action is taken.
The MATTER OF CONCERN is as follows. –
Although the Doctor made several attempts to directly contact Mr Dodson and left a telephone message for him, these difficulties were not reported back to the operative to enable consideration of further action to contact him.
I would be grateful if you could re consider the appropriateness of extending your existing protocols to requirement that locum doctors should inform the operatives in the event of the non response of patients.
The MATTER OF CONCERN is as follows. –
Although the Doctor made several attempts to directly contact Mr Dodson and left a telephone message for him, these difficulties were not reported back to the operative to enable consideration of further action to contact him.
I would be grateful if you could re consider the appropriateness of extending your existing protocols to requirement that locum doctors should inform the operatives in the event of the non response of patients.
Responses
Noted
The Department of Health acknowledges the concerns about staff ratios in care homes, explains that there are no set ratios due to varying resident needs, and refers to existing regulations requiring sufficient qualified staff and the CQC's role in enforcing these regulations. It also outlines changes following the Mid Staffordshire NHS Foundation Trust Inquiry. (AI summary)
The Department of Health acknowledges the concerns about staff ratios in care homes, explains that there are no set ratios due to varying resident needs, and refers to existing regulations requiring sufficient qualified staff and the CQC's role in enforcing these regulations. It also outlines changes following the Mid Staffordshire NHS Foundation Trust Inquiry. (AI summary)
View full response
the Rt Hon Jerery Hunt MP Secretary of State for Health Department of Health Richmond House 79 Whitehall POCI 794073 London SWIA 2NS Michael D Oakley Tel: 020 7210 3000 HM Coroner Mb-sofs@dh-gsi-gov.uk North Yorkshire East Forsyth House Market Place Malton YO17 7LR 2 8 AUg 2013 1 L_ Thank you for your Rule 43 letter of 6 July 2013 regarding the sad deaths of Stanley Dobson and Lesley Taylor: In your letter you asked me to consider reviewing the staff ratios in care homes and establishing national guidelines or regulations: You are correct that there are no set ratios of staff to residents in care and nursing homes. The levels of need of residents can vary great deal and it would simply not be practical to devise ratios which would be suitable for all circumstances. However; all homes are required by law to ensure that sufficient numbers of properly qualified staff are on duty at all times. The Care Quality Commission (CQC) is the independent regulator of health and adult social care providers in England. Under the Health and Social Care Act; 2008, all providers of regulated activities, including NHS, public and independent sector providers, must register with CQC and meet regulations and standards governing the safety and quality of services. Regulation 22 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010,against which CQC registers and regulates providers, states: "Tn order to safeguard the health, safety and welfare of service users, the registered person must take appropriate steps to ensure that; at all times, there are sufficient numbers of suitably qualified, skilled and experienced persons employed for the purposes of carrying on the regulated activity.= CQC is responsible for deciding whether providers are meeting regulatory requirements It is an offence for a provider not to comply with the requirements From JeL6) _
and under the 2008 CQC has a wide range of enforcement powers it can use if it finds a provider is not compliant On 26 March 2013,the Government published Patients First and Foremost, its initial response to the Report of the Public Inquiry into Mid Staffordshire NHS Foundation Trust: The document sets out an initial overarching response on behalf of the health and care system as whole. One of the recommendations was that CQC should introduce new Chief inspectors of Social Care, Hospitals and Primary Care; as well as a set of new fundamental standards of safety and quality, which make the basic standard beneath which care should never fall. CQC published its new three year strategy for 2013 to 2016 and set out how it would introduce the recommendations, as well as setting out its strategic priorities for driving improvement in the quality of care. http:ILwww cqc org uklsites/default/files/media/documents/cqc_strategy_consultatio 2013-2016_tagged_Opdf On 19 July, Andrea Sutcliffe was appointed to be the first Chief Inspector of Social Care: The Chief Inspector will: Make authoritative judgements about the quality of care and recommend that action is taken when identify failing providers Spearhead inspections based on risk, not frequency, together with more in- depth inspections where quality is found to be poor Be the public face of CQC to their respective professions or sectors and lead communicators with the media Produce a single system covering all providers The Department and the CQC will develop the fundamental standards of care to reflect the experiences of service users and carers CQC is currently consulting o the new standards, which; when finalised, will be incorporated in to the registration requirements, alongside other *expected standards' that providers will also need to meet: The regulation requirements will still include a requirement related to staffing, which will be similar to the current requirement referred to above: There is no intention to add specific staffing ratios to the registration requirements. Ihope this response is helpful Thank you for bringing the circumstances of Stanley Hope's and Lesley Taylor s deaths to my attention. Jawves JEREMY HUNT Act, explicit they rating
and under the 2008 CQC has a wide range of enforcement powers it can use if it finds a provider is not compliant On 26 March 2013,the Government published Patients First and Foremost, its initial response to the Report of the Public Inquiry into Mid Staffordshire NHS Foundation Trust: The document sets out an initial overarching response on behalf of the health and care system as whole. One of the recommendations was that CQC should introduce new Chief inspectors of Social Care, Hospitals and Primary Care; as well as a set of new fundamental standards of safety and quality, which make the basic standard beneath which care should never fall. CQC published its new three year strategy for 2013 to 2016 and set out how it would introduce the recommendations, as well as setting out its strategic priorities for driving improvement in the quality of care. http:ILwww cqc org uklsites/default/files/media/documents/cqc_strategy_consultatio 2013-2016_tagged_Opdf On 19 July, Andrea Sutcliffe was appointed to be the first Chief Inspector of Social Care: The Chief Inspector will: Make authoritative judgements about the quality of care and recommend that action is taken when identify failing providers Spearhead inspections based on risk, not frequency, together with more in- depth inspections where quality is found to be poor Be the public face of CQC to their respective professions or sectors and lead communicators with the media Produce a single system covering all providers The Department and the CQC will develop the fundamental standards of care to reflect the experiences of service users and carers CQC is currently consulting o the new standards, which; when finalised, will be incorporated in to the registration requirements, alongside other *expected standards' that providers will also need to meet: The regulation requirements will still include a requirement related to staffing, which will be similar to the current requirement referred to above: There is no intention to add specific staffing ratios to the registration requirements. Ihope this response is helpful Thank you for bringing the circumstances of Stanley Hope's and Lesley Taylor s deaths to my attention. Jawves JEREMY HUNT Act, explicit they rating
Sent To
Response Status
Linked responses
1 of 2
56-Day Deadline
2 Jan 2014
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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 9/10/12 I opened an inquest into the death of Stanley Charles Dodson who, at the date of his deaths was aged 84 years. The inquest was resumed and concluded on 7th November 2013. I found that the cause of death to be: ‐ 1(a) Left Ventricular Failure 1(b) Hypertensive Heart Disease I concluded with a narrative verdict.
Circumstances of the Death
On 1/10/12, Stanley Charles Dodson was found to have died at his home address at 2 Wallis Mews, Guildford Road, Leatherhead, Surrey. Prior to his death he had been prescribed warfarin for a thrombus and methotrexate for his Dermatomyositis, which were withdrawn by his doctor, given his failing short‐term memory and confusion. Mr Dodson had a Mole Valley Community Alarm fitted and at approximately 10pm 30/9/12 he telephoned the operative to ask for a doctor to provide him with medication. The operative then contacted Harmoni to request the attendance of an on call doctor. The doctor responded by telephoning Mr Dodson 3 times but without response and he left a message on his answer phone to ask Mr Dodson to contact him or emergency services if RT3762 necessary. Mr Dodson was found to have died the next day.
Copies Sent To
I have sent a copy of this report to
Mole Valley District Council Chief Coroner Coroners Society RT3762
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.