Pamela George
30 Jan 2026 · Coroner Deborah Archer · Devon, Plymouth and Torbay
The coroner's concerns
1. lack of regular blood tests for acute kidney injury
“Cann House missed an opportunity to carry out regular blood tests on Miss [name redacted] between 23rd May and 29th June. These blood tests may have identified the need to continue to treat acute kidney injury which if left untreated may have affected her resilience to infection. The system for ensuring that discharge summaries are actioned was not available for me to see and I was not clear if any policy on this issue existed.”
2. inadequate management of breast infection leading to sepsis
“The infection which caused her sepsis was a bacterial infection which [REDACTED] told me could only have been successfully treated with antibiotics. I am not satisfied that the breast infection was adequately managed at Cann House it being noted that there was no record of how the breast infection was progressing between 25th May and 27th June 2023 .”
3. insufficient supervision and escalation of medical concerns
“It is likely that Miss [name redacted] needs were too great for the care home and that the withdrawal of 1 to 1 supervision had an effect on the home's ability to care for her. I do think it likely that she was unkempt because of the inability of staff to meet her needs as well as the sepsis This does not however remove the need for close monitoring of medical conditions and appropriate escalation policies to be followed and to happen. The home has been unable to provide me with evidence that they appropriately escalated concerns to Adult Social Care which may have resulted in additional care or Miss [name redacted] being removed to another provider.”
4. unclear documentation of fall and response
“The documentation surrounding the fall, the symptoms seen and measures taken to seek medical input were not clear.”
5. inadequate capacity documentation in care plans
“There was little or no evidence that capacity had been appropriately documented with care plans remaining silent on the issue and records not analysing carefully what steps had been taken to help Miss [name redacted] make decisions.”
6. absence of medication escalation and reporting policies
“There was little or no evidence of policies in place generally at the home and in particular on medication, escalation and reporting of concerns .”