Anthony Slack

1. 1. limited documentation of observations

   “The documentation available at the inquest from the home was limited in detail. As a result, it was difficult to understand what observations had been undertaken by care home staff who were monitoring him.”

2. 2. limited quality observations

   “The evidence given at the inquest was that the observations were of limited quality notwithstanding the diagnosis of Covid 19 and his vulnerability.”

3. 3. admission of untested residents

   “The inquest heard that after the home went into lockdown Covid 19 was found in residents within the home. At the inquest the home were unclear I if staff had brought it into the home or if the admission of residents from the community who were not tested for Covid 19 before admission were the cause of it entering the home. There was no risk assessment in place relating to admission of new residents”

4. 4. uncertain PPE requirements

   “Staff were unclear as to the PPE requirements as a result of changes to the guidance that were occurring on a regular basis and it was unclear how changes were being shared with staff and implemented.”

5. 5. ambulance delay

   “The inquest heard that the ambulance was delayed due to shortages of available ambulances. The inquest was told this was driven by a number of factors. This included staff absences due to the need to self-isolate awaiting testing and the increased cleaning needs in relation to ambulances required by Covid 19. The inquest was told that at some points in the day and in some acute trusts, ambulance crews were being supported by on-site cleaning crews. This meant quicker turnaround times and”

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