1. EPSO Conference September 2015:
Risk Case Study For Discussion
Hamish Young, CQC

2. Case study: background
A coroner will write a ‘Regulation 28 Report’ if, during an inquest they find that action could be taken to prevent a similar death in future.
In one case, a resident in a care home for older people (Mr R), was administered Clozapine in error (meant for another resident) and was given ten times the recommended dose.
Suffering from an altered level of consciousness and confusion, emergency services were called immediately, and Mr R was admitted to hospital. While responsive on arrival, Mr R later became unresponsive.
While in hospital Mr R’s health improved, and arrangements were made for discharge, however his health deteriorated and he died.
A post-mortem found that Mr R died of ‘natural disease process’, but the pathologist was unable to exclude the possibility that death was hastened by the inappropriate administration of Clozapine.

3. How was the supervisory organisation involved?
Although QCQ’s inspection and monitoring methodologies have changed since this incident, CQC was involved in the following ways, as would have been the case with all care home locations:
Inspection - Planning, inspecting, publishing outcomes and monitoring compliance/non-compliance.
Monitoring information received:
From providers who are legally obliged to notify CQC of incidents/events
From service users/relatives
From wider health/social care sector and external organisations
As part of national collections
Analysis –
Of risks by location/provider,
Of notifications by location/provider,
Of location/provider by portfolio holder.

4. What kind of data was available and how was this data used?

5. What kind of data was available and how was this data used?
The majority of monitoring information noted in the previous table was read and responded to by the portfolio holder (inspector). There were a number of sources of data and some missing data in terms of notifications from the provider. CQC relied on the portfolio holder to monitor the information for all portfolio locations, and decide what, if any action was required.
The June 2013 SAS data file sent to the inspector and their manager, reports five risks (negative comments (QRP), notifications and emergency hospital admission outliers, safeguarding, lack of Registered Manager (RM)). The SAS report did not specifically mention the high number of risks at the care home, as it had recently been inspected. QRP not available at this time.
Considering the outcome of the September 2012 inspection, CQC staff identified this location as a risk, as noted on the Risk Register in February 2013.

6. Could this have been prevented?
Difficult to say whether this could have been prevented, but this case highlights a number of key questions about care home regulation*:
Inspecting medicines management in care homes – none of the three inspections between Sept 2012 and May 2013 looked at medicines. When inspected in Feb/March 2014 the standard was found non-compliant in relation to a lack of clear guidance, and staff being unable to concentrate during administration. Enforcement action followed. The coroner suggested annual inspection of medicines.
The absence of a Registered Manager – no registered manager in place between March and December Death occurred July 2013.
Inspectors relied on to monitor information – Inspectors required to monitor what information is and isn’t (e.g. notifications in this case) being received about their locations, and decide the action required.
How to monitor risky locations - location was on the risk register in Feb 2013 as a result of the Sept 2012 inspection results.
* CQC’s inspection/monitoring methods have changed since this incident took place.