Acknowledgement
The Torbay and Devon Safeguarding Adults Partnership would like to thank the Devon Care Homes Collaborative for their contribution in co-producing this provider briefing to raise awareness of the learning identified.
Background and key events
Tony had a successful and varied career, mostly as an electrical engineer. He served on two tours of HMS Belfast and then as a maintenance manager for Selectro. Tony lived in France from the early nineties until he returned to the UK in 2008.
Tony was diagnosed with several serious health issues over a number of years. These included bladder cancer, chronic obstructive pulmonary disease and rheumatoid arthritis which contributed to a sharp decline in Tony’s health in the last few years of his life. His mobility worsened, he experienced visual disturbances, a decline in his memory and he became noticeably frailer. Tony became more vulnerable to falls exacerbated by further diagnoses of osteoarthritis and postural hypotension.
In November 2020 Tony was admitted to an acute hospital emergency department with concerns of reduced mobility, reduced appetite and a urinary tract infection. Following treatment he was transferred to a Community Hospital setting for ongoing rehabilitation. Tony fell during this time sustaining a fractured hip resulting in a transfer back to acute care for surgery. Two weeks later Tony was transferred back to the Community Hospital setting for rehabilitation and a further three weeks later to a residential care home for ongoing rehabilitation. Less than two weeks later he was admitted back into acute hospital care with a suspected dislocation of his new prosthetic hip joint and emergency surgery was completed.
Tony passed away two days later. This was in February 2021 when the UK was in its third lockdown period of the covid19 pandemic.
Government policy, legislation and guidelines fundamentally changed working practices across the Health and Social Care landscape during this time. These impacted not only on those in need of care, but also on their loved ones.
Transition for adults between hospital settings and care home
Following periods of being an inpatient at both an acute hospital and a community hospital Tony was clinically assessed as being suitable for ongoing care and rehabilitation in a residential care setting. Consequently, he became a temporary patient in respect of another GP practice. The review found that the ‘incoming’ practice had limited access to electronic records which resulted in an increased dosage of prescribed medication which was likely the cause of Tony’s dizziness.
There was also a home visit completed by a GP due to Tony experiencing shortness of breath and although it was agreed that amoxicillin be prescribed that day, on a Friday, this plan did not start until the following Monday.
Learning
Medication prescribing – The residential care home has put in place actions to improve client/patient safety around medication prescribing:
· A member of the care staff accompanies the GP when visiting residents and prescribing medication.
· A pharmacy is now being used that has extended opening hours to ensure that medication is available as early as possible.
· A new process, where on admission, they request a GP summary from the client’s own surgery which is then checked to ensure information is carried across to the care home’s records and ‘incoming’ GP practice.
Shared responsibility – The review acknowledged that in the case of Tony both GP’s and registered providers have taken action to strengthen their processes. The review highlights the importance of the shared responsibility between GPs and registered providers to ensure that the correct medication is given at the correct time.
TDSAP Medicines Management and Safeguarding guidance – The Torbay and Devon Safeguarding Adults Partnership published guidance in October 2022 on ‘Medicines Management for organisations who provide care and support’ which you can access here
The Devon Care Home Collaborative also led on the development of ‘A Quick Guide for when to raise a safeguarding concern’ which was published in November 2022 and which you can access here
The Safeguarding Adults Review for Tony recommended that all provider network partners be reminded of the above mentioned guidance to support best practice.
You can access the full SAR Tony report here