David Sheppard
8 May 2017 · Coroner Louise Hunt · Birmingham and Solihull
This report repeats 1 earlier warning, and was raised again 2 times later. See the linked reports.
The coroner's concerns
1. communication breakdown among staff
“41. Communication. There are three areas where communication is a concern: a. The initial nurse who attended the deceased after the emergency call had poor English and needed to give evidence at the inquest through an interpreter. The carer who started CPR had very poor English and also gave evidence through an interpreter. The evidence heard at the inquest was that the response to this emergency was chaotic. Inability of staff to communicate with each other contributed to the chaos and poor”
2. inadequate record keeping
“Record keeping. Staff failed to keep an acute and contemporaneous note of the events that occurred with timings. This made reconstruction of the event extremely difficult.”
3. insufficient first aid training
“Training. Several of the staff who gave evidence had not received first aid training. They did not understand the signs of choking displayed by the deceased.”
4. poor post event investigation
“Post event investigation. The quality of statements produced by staff immediately after the event was extremely poor. Subsequently staff had a very poor recollection of what happened which seriously hampered the inquest. Direction needs to be given to ensure that accurate and contemporaneous statements are taken after such an incident to ensure events are accurately recorded to enable the correct lessons to be learnt.”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“He accepted in the course of his evidence that his record keeping was inadequate.”
This report
“Staff failed to keep an acute and contemporaneous note of the events that occurred with timings.”
Closely relatedConfidence 0.90 · high
This report
“Staff failed to keep an acute and contemporaneous note of the events that occurred with timings.”
Later report
“(1) The record keeping was inconsistent and lacked detail on general wellbeing.”
Closely relatedConfidence 0.90 · high
This report
“The initial nurse who attended the deceased after the emergency call had poor English and needed to give evidence at the inquest through an interpreter.”
Later report
“The home relied on agency staff who the inquest was told struggled to have sufficient grasp of the English language to understand instructions given and to communicate with residents.”
Responses
David-Sheppard-Response.pdf ↗· Boldmere Court Care Home
Stated action
“the provider has taken a number of measures to address concerns including, but not limited to, the provision of training with first aid, CPR and choking prioritised in the induction process, as well as documentation training sessions and the introduction of an incident reporting questionnaire”