Peter Seaby
27 Feb 2023 · Coroner Jacqueline Lake · Norfolk
The coroner's concerns
1. inadequate supervision of residents requiring one-to-one care
“Evidence was heard at the inquest of the "informal approach" taken with regard to arrangements as to who would provide supervision of residents, including on a one to one basis and who would cook and prepare their meals, including those residents who were subject to a specific SALT dietary plan”
2. insufficient staffing levels
“It was not clear from the evidence that the staffing levels at Oaks and Woodcroft Care Home are sufficient to provide care for residents, including those requiring one to one supervision and supervision out of the Home and to cover individual activities”
3. lack of internal review and oversight
“Mr [name redacted] died in 2018 and this is the second inquest into Mr [name redacted] death. There has still been no internal review carried out following Mr [name redacted] death which was unexpected. No Manager was present throughout the inquest and when some elements of evidence were put in dealing with Regulation 28 matters there was some surprise at some of the points raised and evidence heard during the course of the inquest”