Ben King
20 Jul 2021 · Coroner Jacqueline Lake · Norfolk
The coroner's concerns
1. residential care for persons with learning disabilities and mental health illness without adequate oversight
“Jeesal Akman Care Corporation (Directors: ) was the care provider for JCP and closed in May 2021. However, Jeesal Holdings Ltd (JHL) and Jeesal Residential Care Services Ltd (JRCSL) and possibly other linked companies with the same Directors, continue to provide residential care to persons with mental health illness, learning disabilities, complex needs and physical disability. The concerns raised at the inquest could apply to residential care offered by these companies and unless such concerns”
2. failure to monitor residents with 1-to-1 observation
“CCTV was shown at the inquest which revealed [the deceased] had been assaulted in the hours prior to his death and also that 1 to 1 observation was not carried out in accordance with the Observations Policy”
3. non-compliance with dietary guidance
“Basic dietary advice and guidance provided was not followed by staff”
4. inadequate staff training on dietary management
“The use of the Dietician in training of staff was reduced in 2017 from one day's training to an hour's power point presentation”
5. incomplete health monitoring records
“Important records were not completed by staff, eg Food intake, Exercise, Weight and vital observations”
6. lack of regular exercise for residents with learning disabilities
“Evidence was heard that exercise was not regularly offered to [the deceased] and when the Sports Instructor was absent for lengthy periods of time, there was no replacement”
Responses
2021-0250-Response-from-Jeesal-Residential-Care-Services_Published.pdf ↗· Jeesal Residential Care Services
2021-0250-Response-from-Norfolk-and-Norwich-University-Hospitals_Published.pdf ↗· Norfolk and Norwich University Hospital
Stated action
“the Hospital has put in place a system for GPs to contact the Hospital if information is unclear - via a nhs.net email account, which is manned 24/7 by the ED admin team, who seek the most appropriate person to respond;”