Norman Leadbeater: Prevention of future deaths report

Hospital Death (Clinical Procedures and medical management) related deaths

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Date of report: 27/06/2024

Ref: 2024-0346

Deceased name: Norman Leadbeater

Coroner name: Catherine McKenna

Coroner Area: Manchester North

Category: Hospital Death (Clinical Procedures and medical management) related deaths

This report is being sent to: Evolve Services

[REDACTED], Director, Evolve Services, Bury Business Centre, Unit 23, Kay Street, Bury, BL9 6BU
I am Catherine McKenna, Area Coroner for the Coroner area of Manchester North
I make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013
On 24 January 2024 an investigation into the death of Norman Leadbeater was commenced. The investigation concluded at the end of the inquest on 27 June 2024. I recorded a conclusion of Natural Causes.

The medical cause of death was 1a) Aspiration Pneumonia 1b) Parkinsons Disease 2) Liver Cancer
Norman Leadbeater had a past medical history of advanced Parkinsons disease, vascular dementia and presumed liver cancer. Following a swallowing assessment on 10 November 2023, he was advised to have thickened fluids to prevent chest aspiration. He was admitted to Fairfield General Hospital on 27 November and diagnosed with aspiration pneumonia secondary to Parkinsons disease. His medications were altered to liquid and dispersible forms. He was readmitted to hospital on 7 January and diagnosed with a further aspiration pneumonia. Despite treatment, he deteriorated and died on 14 January 2024.
During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows:
Mr Leadbeater had been in receipt of domiciliary care from Evolve Services since October 2023. The care included the administration of medication. When a concern was raised that the carers had not been thickening fluids appropriately, the Community Commissioning Team at Bury Council undertook an investigation and found that the prescribed thickener was not listed on the Medication Administration Record (MAR) and that the care plan in place for Mr Leadbeater did not contain sufficient detail for care staff to safely and correctly administer thickened fluids. In February 2024 and following its investigation into the concerns regarding Mr Leadbeater’s care, Bury Council Community Commissioning Team recommended that Evolve Services undertake a number of remedial actions. This included an immediate management audit of MAR for those service-users in receipt of medication support and liaison with GPs and Pharmacists to ensure that the medication listed for each service-user is up to date and accurate. The Court heard that four and half months since the recommendation was made, Evolve Services have not yet completed the management audit of MAR for those service users in receipt of medication support. The representative from Evolve Services who attended the inquest was unable to provide the Court with a timescale for completion of this work or the number of service users this affects.
In my opinion action should be taken to prevent future deaths and I believe each of you respectively have the power to take such action.
You are under a duty to respond to this report within 56 days of the date of this report, namely 23 August 2024
I, the Area Coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:-
The family of the Deceased
Bury Adult Social Care
The Care Quality Commission
Bury Integrated Care Partnership
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary from. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me the coroner at the time of your response, about the release or the publication of your response by the Chief Coroner.
927 June 2024