Gloria Simon (1)
31 Oct 2025 · Coroner David Lewis · Liverpool and Wirral
The coroner's concerns
1. inadequate assessment of vulnerable elderly patient in care home
“The GP to whom this case was allocated told the court that he did not know that [the deceased] was in a care home setting (as opposed to a nursing home setting), which had no clinical staff of any kind, despite having previously visited the premises and despite the clerical assistant's note on a Consultation Report that this was a request from 'CH'. He indicated that it was as a result of this misunderstanding was that he did not visit the premises to make a face-to-face clinical assessment.”
2. misinterpretation of low oxygen saturation leading to inadequate clinical response
“In its typed 'Request for Care' form, the care home noted that [the deceased]'s oxygen saturations were 84% and described them (correctly) as 'very low'. The time when the observations were taken was not stated. Despite a clerical assistant at the GP practice having noted down correctly that the reading was 84%, the GP misread the papers as saying 94% and described the oxygen saturations as 'low'.”
3. lack of systemic safeguards for care home information
“The court is concerned that a recurrence of this situation could leave vulnerable elderly patients with inadequate care. The court would like to know whether measures are being taken to ensure that those in the practice are properly informed about the nature and status of resident institutions with whom they have contact.”
4. failure to conduct face-to-face assessment despite warning signs
“The court considers that this elderly vulnerable patient should have had a face-to-face clinical assessment but did not because of insufficient attention to detail and/or clinical curiosity on the part of the GP. The court would like to understand how the practice can ensure that this is not something that will recur.”