George Goldby
11 Apr 2018 · Coroner Jane Gillespie · Nottinghamshire
The coroner's concerns
1. lack of awareness of SALT recommendations and supervision needs
“The nursing home staff were unaware of the SALT recommendations regarding Mr [name redacted] need for one to one supervision and dietary requirements”
2. non adherence to SALT recommendations causing choking incidents
“Mr [name redacted] SALT recommendations were not being adhered to on 26.12.16 when he choked and recovered, nor on 20.03.17 when he choked again, directly leading to his death”
3. missed re-referral and care plan review opportunities
“There were three missed opportunities to re-refer Mr [name redacted] to SALT and to review his care plan and dietary requirements”
4. non reporting of choking incident
“The choking incident on 26.12.16 was not reported in line with Stoneyford's internal policy”
5. inadequate and disorganised record keeping
“The care plan records and in particular, the choking risk assessments in respect of Mr [name redacted] were inadequately completed and record keeping has been incomplete and/or wholly disorganised”
6. archived SALT assessment not accessible on care plan
“The SALT assessment in respect of Mr [name redacted] had been archived and was not present on his care plan file at the time of his death”
Responses
2018-0104-Response-by-HC-One.pdf ↗· HC-One
Stated action
“Allocation of staff to and practical supervision of Residents whilst eating and drinking to assess any issues.”
Stated action
“Completion of the swallowing risk assessment with independent validation from another senior colleague to ensure accurate scoring and corresponding actions to mitigate risk are adhered to. This system remains in place with the Care Manager reviewing and signing off any updates.”
Stated action
“All Residents whose assessment indicated having reached the appropriate threshold of need have been referred to the Speech and Language team (SALT) service via the GP for review- New referrals have also been actioned and follow-ups reviews have been planned by SALT- 2 existing Residents are due a review, which have been scheduled.”
Stated action
“The Care Manager has taken responsibility for oversight of communication between SALT and colleagues at the home to ensure optimum communication and appropriate escalation for support.”
Stated action
“Once this initial work was completed at Stoneyford, we sought advice from senior clinicians within the company for governance and oversight, which resulted in the care plans being rewritten to specify the detailed plan of care for each Resident.”
Stated action
“Additional advice was sought from the company Hospitality specialist to establish if there were any further processes or mechanisms to help support the safe and effective management of people who require a specialist diet. As a result we have introduced a new system of dining registers with quick reference guides, which were put into place and help colleagues or any agency workers to reflect the handover documentation.”