Rhys Williams
15 Dec 2014 · Coroner John Pollard · Manchester (South)
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of training of carers
“There appeared to be a lack of training (in a number of areas) of the carers having immediate care of Dr Williams. | was told that they should all undertake e-learning but it was far from clear as to how (or whether) this was monitored and checked”
2. misplacement of profile beds
“2. Despite the assurances of the Managing Director, who was very frank and helpful in her evidence, | remained far from satisfied that all the staff members were aware of the rules relating to the positioning of the 'profile beds' which are on caster wheels. Because of this lack of certainty amongst the staff members, Dr Williams' bed was placed, allegedly, against the wall when apparently this should not have been the case. Are all the staff members now clear as to the Rules relating to the”
3. inadequate nursing care funding
“During the course of the evidence it became apparent that public money was being sent to Sunrise Senior Living for the provision of nursing care for Dr Williams. Whilst | accept that a nurse was present on site albeit in the other part of the Home, this was accepted by the Managing Director as not amounting to the provision of nursing care. The payment was apparently 'credited' against the account of Dr Williams, but | am concerned that as a result of this apparently flawed system, he was not in”
4. bed brakes not applied when staff absent
“The requirement for bed brakes to be properly applied when the staff members are not in the room should be an absolute requirement and this should be reinforced in writing to all staff.”
5. failure to transfer care information
“There was an apparent failure by the staff (notably the managers who changed on a number of occasions) to pass relevant information to their successors, and the daughter of Dr Williams had to reiterate the same information several times. This led to a lack of confidence by the family of the deceased that his care needs were properly being made known to those having care of him.”
6. inaccurate care notes
“Care notes were completed for the full period of the night shift of the 3% to the 4°”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“Are all the staff members now clear as to the Rules relating to the positioning of the profile beds? Is there a rule about the need for crash mats and sensor mats on both sides of the bed?”
Later report
“The evidence was that fall sensor mats had been placed either side of Mr. [name redacted]' bed on top of crash mats. At the time of his fall on the 3% May 2016 the sensor mats did not sound an alert”
Responses
2014-0558-Response-by-Sunrise-Senior-Living.pdf ↗· Sunrise Senior Living
Stated action
“we now have incorporated this into our manual handling training which is mandatory for all care and nursing staff. Compliance is monitored via manual handling training compliance reports, which are reported weekly to the business. Any concerns on compliance are acted upon by the Director of Operations.”