Frederick King
15 Nov 2022 · Coroner Jenny Goldring · Berkshire
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. inadequate fluid intake
“[name redacted] did not receive adequate fluid in the 2 days prior to his death (985 and 770 ml)”
2. inadequate record keeping
“Inadequate record keeping in the Birchwood Care made it difficult to obtain the relevant records for the Inquest and the records obtained were incomplete for example in terms of what recording timings of fluid provision, whether pads were wet/dry and also family concerns regarding health were not recorded and conveyed”
3. absence of on‑site manager
“There was no manager on the ground of the care home in the 3 days prior to [name redacted]'s death”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“Records of routine checks on residents are not made. Therefore whilst it was asserted that Mr [name redacted] was checked hourly throughout following the fall there is no evidence that the checks were carried out”
This report
“Inadequate record keeping in the Birchwood Care made it difficult to obtain the relevant records for the Inquest and the records obtained were incomplete”
Identical hazardConfidence 0.90 · high
Earlier report
“The record keeping was inconsistent and lacked detail on general wellbeing.”
This report
“Inadequate record keeping in the Birchwood Care made it difficult to obtain the relevant records for the Inquest and the records obtained were incomplete”