John Gregory
20 Mar 2020 · Coroner ME Hassell · London Inner North
The coroner's concerns
1. insufficient oral fluid intake
“Mr [name redacted] died because he had not been drinking enough, though his Alzheimer's was not end stage, and before he was admitted to hospital he had been mobile; able to wash, dress and feed himself; and enjoy a good quality of life.”
2. inadequate supervision and restraint in wheelchair
“On the day he was readmitted to hospital from Muriel Street, Mr [name redacted] family found him slumped unconscious in a public area of the home, a fact unnoticed by any member of staff. He was not properly strapped in to a wheelchair, slipping down because his feet were not on the foot rests. He was cold and inadequately dressed, with his shirt undone and not wearing socks. By then Mr [name redacted] was not capable of dressing himself.”
3. inaccurate fluid intake documentation
“On his last day at the home, Mr [name redacted] was described in the nursing notes as drinking, but his chart showed that he had drunk nothing since a cup of tea at 8.20am. The ambulance was called at 5.17pm. The fact that he had not drunk the whole day was not escalated to a senior member of staff and there was no evidence that any steps had been taken to deal with this.”
Responses
2020-0073-Response-from-Care-UK_Redacted.pdf ↗· Care UK
Stated action
“Consequently, the training has been improved, and the manual handling training now includes a specific section on wheelchair safety guidance. This includes highlighting and working through the”
Stated action
“Following this, it was identified that the training surrounding the use of wheelchairs could be strengthened. Consequently, the training has been improved, and the manual handling training now includes a specific section on wheelchair safety guidance.”
Stated action
“Muriel Street has also increased staffing levels since this incident, and there is now an increased senior presence on each floor with a senior manager (Deputy Manager, Clinical Lead or Care lead) based in each nursing office and the addition of a team leader who supports to carry out regular walk arounds of their floor / unit.”
Stated action · April 2020
“since April 2020, in accordance with Care UK policy Muriel Street has now ensured that the welfare check sheets are completed during the day alongside the other documentation”
Stated action
“Additionally, where a resident's care plan requires the use of a wheelchair, a hard copy of the guide is placed into that resident's care plan folder in their room”
Stated action
“a laminated copy of this guide at every nurse's station to ensure that the guide is easily accessible.”