Richard Burgess
19 May 2021 · Coroner Derek Winter · Sunderland
This report repeats 2 earlier warnings, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of multidisciplinary team with appropriate skills and competencies
“the provision of a multidisciplinary team of professionals with suitable skills, qualifications and competencies commensurate with their role and the specialty of dementia care”
2. lack of proactive prevention model for dementia care
“a prevention model and approach for dementia care that proactively uses detailed assessment, intervention and evaluation of changing care, needs and risks of the individual in order to provide therapeutic interventions and reduce the need for medication”
3. insufficient assessment of individual's difficulties and risks
“the evidence of assessments or the application of assessments of the impact of a person's difficulties, including cognitive and neurological difficulties, polypharmacy, psychological and personality, mental and physical health, social, environmental and care practices, emotions, belief and thoughts of the person”
4. lack of continuous family engagement in triangle of care
“a continuous engagement with the family in the”
5. insufficient person-centred care and social environment
“a focus on the person, asserting absolute value of the person, an individualised approach, while understanding the world from the person's perspective and provision of a social environment that supports psychological and physical needs”
6. failure to implement policies effectively
“converting policy into practice”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“No further enquiries were made to identify familial or social support which might or could have been enlisted or alerted to her presenting danger”
This report
“- a continuous engagement with the family in the "triangle of care", including regular communication and updating life stories”
Closely relatedConfidence 0.90 · high
Earlier report
“There was no clear policy about how a family could be effectively engaged by the CMHT;”
This report
“- a continuous engagement with the family in the "triangle of care", including regular communication and updating life stories;”
Closely relatedConfidence 0.90 · high
This report
“- the provision of a multidisciplinary team of professionals with suitable skills, qualifications and competencies commensurate with their role and the specialty of dementia care;”
Later report
“There were multiple repeated missed opportunities to co-ordinate the Deceased's care with the convention of multi-disciplinary and multi-agency meetings despite known escalating risk.”
Responses
2021-0163-Response-from-Department-of-Health-and-Social-Care_Published.pdf ↗· Department of Health and Social Care
2021-0163-Response-from-St-Nicholas-Hospital-Published.pdf ↗· Cumbria
Stated action · 27 July 2021
“the Trust employs specialist Psychiatrists who are trained to work with patients with dementia, in addition to Care of the Elderly nurses, who provide training and support to staff. The Trust also employs Activity Coordinators who are all actively involved as part of the MDT process and has recently trained 10 members of staff to provide dementia care mapping training across the relevant wards.”