Robert Davidson
13 Oct 2016 · Coroner Louise Hunt · Birmingham and Solihull
The coroner's concerns
1. lack of training on basic processes
“During the inquest | heard evidence that Health care staff had not been trained on basic process as follows: ¢ Making 999 calls - to obtain an outside line caller's needed to first dial”
2. insufficient training for health care assistants
“The two HCA's had no experience or basic training before starting work as HCA's”
3. failure to communicate critical health information during patient transfer
“The deceased PICA behaviour was not highlighted or identified on his transfer between care homes”
Responses
2016-0363-Response-by-Avery.pdf ↗· Department of Health and Social Care
2016-0363-Response-by-Care-Quality-Commission.pdf ↗· Care Quality Commission
Stated action
“The provider should have procedures to follow in an emergency and staff should be trained in these procedures.”
2016-0363-Response-by-Department-of-Health.pdf ↗· Department of Health and Social Care
2016-0363-Response-by-NHS-England.pdf ↗· NHS England
2016-0363-Response-by-Priory-Group.pdf ↗· Department of Health and Social Care
Stated action · forthcoming issue of our quarterly Safety 1* bulletin
“«This incident and the lessons learnt from it i.e. to ensure effective communication at the point of a resident's transfer or discharge to another provider will be raised in a forthcoming issue of our quarterly Safety 1* bulletin which is shared across all of our Amore Care Homes.”