Mark Athias
28 Jan 2022 · Coroner Kevin McLoughlin · West Yorkshire (East)
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of sterile replacement catheters
“The nursing home did not have sterile replacement catheters in stock, despite being aware that Mr [name redacted] had difficulties with his catheter, which had necessitated it being replaced twice in previous weeks. The mistakes made in ordering replacements had not been detected by the managers in the nursing home.”
2. inadequate fluid intake and output monitoring
“The catheter care plan had identified the need for his fluid intake and output to be monitored. The contemporaneous records kept were, however, inadequate. This hindered any assessment of his urinary problems. The managers in the nursinq home had not noticed the inadequacy of such records.”
3. missing handover record
“The handover record for 2 July 2021 was missing, having allegedly been overwritten. The managers in the nursing home did not appreciate this until an Adult Safeguarding Investigation was underway.”
4. deficient record keeping
“In order to ensure instructions were complied with, and without checks to ensure the contemporaneous records required to be kept were actually being maintained, there is a risk deficient record keeping could continue.”
5. insufficient managerial checks on record keeping
“Managers of nursing homes should make checks sufficiently often to ensure the records required to be kept actually exist, and that they are preserved, so as to facilitate an analysis of trends in the medical condition of patients in the care of the nursing home”
Linked reports
Identical hazardConfidence 0.90 · high
This report
“The catheter care plan had identified the need for his fluid intake and output to be monitored. The contemporaneous records kept were, however, inadequate.”
Later report
“Instructions given to monitor and record Ms [name redacted] food and fluid intake were not adequately followed.”
Responses
2022-0024-Response-from-Exemplar-Health-Care_Published.pdf ↗· Department of Health and Social Care
Stated action · 2022
“The nursing home did not have sterile replacement catheters in stock, despite being aware that Mr [name redacted] had difficulties with his catheter, which had necessitated it being replaced twice in the previous weeks. The mistakes made in ordering placements had not been detected by managers in the nursing home.”
Stated action · 2022
“after Mr [name redacted]' death, weekly stock checks were implemented at Copperfields in order to ensure a sufficient level of stock is maintained at all times.”
Stated action · February 2022
“The EMAR system also has a Dashboard that flags an alert in the event any stock is running low. The levels of stock are therefore no longer dependent on visual assessment although, as explained by Ms , weekly visual stock checks still take place”
Stated action · 2022
“A new Registered Home Manager and new Clinical Nurse [name redacted] are now in place. In addition, a second full time Clinical Nurse [name redacted] and a full time Head of Care have been employed.”
Stated action · 2022
“specific steps have also been taken to ensure greater management overview, and quality assurance, of record keeping and documentation. During Mr [name redacted]' residence at Copperfields the relevant governance processes (EQA- Exemplar Quality Assurance) were paper based. However, the majority ofthe EQA processes have now been moved to a digital platform.”
Stated action · 2022
“The individual team leaders have been trained that they are responsible for ensuring that there are no gaps in the supplementary documentation, that all documentation is complete before the end of their shifts and that this is reported to the unit managers, who in turn report it in a daily "take 20 meeting”