Dylan Henty

“While it appears to have had no bearing on the circumstances of [the deceased]'s death, | was concerned to hear evidence of [the deceased] suffering a seizure in a bath while unsupervised. Similar episodes elsewhere in the country have resulted in criminal prosecutions. It is not clear to me whether reports were made to the CQC, GP and/or care coordinator. You may wish to reflect on the need for clear guidance and training to all staff on the arrangements for those residents with a known risk of seizure to take baths”

“[the deceased]'s GP was unaware of previous incidents of hoarding. He felt this was something that should have been brought to his attention. You may wish to reflect on the need for clear guidance and training to all staff in such matters. Similarly, you may wish to reflect on the need for those in management positions to ensure rigorous compliance with the relevant standards.”

“Linked to the issue of hoarding is the question of how to ensure a resident is compliant with taking medication prescribed to him. It was accepted in evidence that, given the discovery of the medication in [the deceased]'s room, the system in place must have failed. It was recognised in court that there are limits to enforcing residents to take medication. Nevertheless, there needs to be a robust system in place and where there is doubt about a resident's compliance, notification should be made to the”

“There appeared to have been inconsistency in the reporting of incidents of absconding. You may wish to reflect on the need, in similar circumstances, for reports to be made to the GP, care coordinator and CQC. Further, you may wish to consider at what point there is a need for such matters to be considered at MDT level, for example, to consider whether current residential arrangements continue to be appropriate.”

“Linked to the above are the arrangements put in place to monitor residents where there have been previous incidents of absconding. There needs to be a clear recognition of what is realistic particularly when set against the desire to ensure the Lodge remains the resident's home.”