Elsie Clarke
20 Aug 2015 · Coroner John Pollard · Manchester (South)
The coroner's concerns
1. lack of training in emergency call procedures
“There was an apparent lack of training for the staff at Hurst Hall in the appropriate use of calling either 999 or 111”
2. ignorance of temporary GP registration process
“The staff did not know how to arrange for the attendance of a GP fora resident who was not yet fully registered with a local GP”
3. inadequate resident observation
“The level and quality of observation of the residents were very poor and did not include even some of the most basic issues such as whether the patient was warm, thirsty etc”
4. failure to report to CQC
“There seemed to be a complete lack of understanding about the legal requirement for prompt reporting of such matters as occurred in this case to the Care Quality Commission”
5. staff fail to request GP assessment
“When a local GP was visiting another patient at the Home, the staff seemed unaware that they could and should have asked that doctor to look at this patient/resident”
6. missing nutrition and hydration documentation
“There was a complete failure to maintain food and hydration records”