Donna Levy
31 Aug 2023 · Coroner Graeme Irvine · East London
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of personal care and provision of fast food only
“Since 2020 Ms [name redacted] had been provided with domiciliary care commissioned by the local authority. At the time of her death twice daily visits were undertaken. Ms [name redacted] was utilising state funded domiciliary care visits to deliver fast food to her home, no personal care was being provided. Carers had escalated to the local authority Ms [name redacted] reluctance to accept personal care and raised safeguarding reports regarding Ms [name redacted] living conditions.”
2. failure to escalate care
“In the two months prior to her final admission into hospital Ms [name redacted] was being regularly assessed by district nurses, the community matron and her GP. Despite the obvious nature of her deteriorating health, no meaningful steps were taken to escalate the care she received to mitigate the risks of her self-neglect.”
3. assumption of capacity
“The inquest heard that as Ms [name redacted] was believed to have capacity throughout this period, and consequently it was determined that there were on practical steps that could have been taken to improve the provision of care to her.”
4. absence of MCA assessment
“No formal Mental Capacity Act assessment was ever undertaken or considered.”
5. lack of mental health referral
“No formal referral was made to mental health services regarding Ms [name redacted] reluctance to take advantage of offered care.”
6. inadequate serious incident investigation
“The Trust responsible for community care did not undertake a Serious Investigation. The decision was justified on the basis that Ms [name redacted] pressure sore was insufficiently significant to justify further inquiry. The decision was, in the view of the court flawed as evidence heard indicated that the pressure sore was in fact far more serious than appreciated at the time of community treatment. Further, restricting the scope of a serious incident report to the extent of a single pressure sore, neglected”
Linked reports
Closely relatedConfidence 0.85 · high
This report
“Since 2020 Ms [name redacted] had been provided with domiciliary care commissioned by the local authority. At the time of her death twice daily visits were undertaken. Ms [name redacted] was utilising state funded domiciliary care visits to deliver fast food to her home, no personal care was being provided.”
Later report
“Poor standards of communication between the domiciliary care company, the local authority and NHS trust resulted in a failure to identify the deterioration in Mr [name redacted] living conditions and health.”
Responses
2023-0315-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
Stated action · 09/11/23
“include: increasing nursing capacity; holding weekly multidisciplinary Complex Case discussion meetings; updating the risk escalation process; devising standardised operating procedure relating to how district nurses conduct their daily handovers; providing relevant training for health and social care staff; making the completion of mental capacity assessments in complex cases mandatory; undertaking risk assessments to identify anxiety and depression scores; increasing frequency of high risk cases”
2023-0315-Response-from-North-East-London-Foundation-Trust.pdf ↗· North East London Foundation Trust
Stated action
“Engage will the London Borough of Redbridge in weekly Complex Case Discussion meetings involving all 5 Health and Social Services localities and areas of responsibility.”
Stated action
“Introduce two new and full-time senior band 8a nurses.”
Stated action
“Review, revise and disseminate the risk escalation process with health and social care staff.”
Stated action
“Devise a standardised operating procedure relating to how District Nurses conduct their daily handovers.”
Stated action
“Provide Professional Curiosity training for health and social care staff.”
Stated action
“Provide legal training on Court of Protection referrals for health and social care staff.”