James Capstick
2 Aug 2024 · Coroner Nicholas Shaw · Cumbria
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. inaccurate medical documentation
“that care had improved since Reg's death but he still had concerns about care given and had to visit regularly every week to check residents -the only one of six homes he covers that requires this level of support. He said it was a struggle to provide good quality care and felt this report would be helpful -as I stated at inquest it is not intended in any way to be punitive but to put focus on areas that may be improved. A particular concern was clear evidence that examinations entered into Reg's notes”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“During the course of the inquest, the evidence revealed concerns with the implications of the evidence of three witnesses employed by NHS Professionals at times when the deceased was already dead.”
This report
“(1) To Westmorland Court. The General Practitioner who came to give evidence said that care had improved since Reg's death but he still had concerns about care given and had to visit regularly every week to check residents -the only one of six homes he covers that requires this level of support. He said it was a struggle to provide good quality care and felt this report would be helpful -as I stated at inquest it is not intended in any way to be punitive but to put focus on areas that may be im”
Responses
2024-0429-Response-from-CQC.pdf ↗· Nursing and Midwifery Council
Stated action · 1 December 2021
“We are grateful for the details provided in your report and confirmation of the outcome following inquest. With regards your query in relation to CQC making further enquiries, we have taken action as outlined below. CQC were informed of the outcome of the local authority safeguarding investigation into the use of CPR on 1 December 2021 including actions to be taken to prevent further incidents. Actions included internal investigation by the provider, audit of the incident, a refresher of basic”
2024-0429-Response-from-NMC.pdf ↗· Care Quality Commission
Stated action
“we have passed this information on to our Employer Link Service (ELS) and to the New Referrals team to make enquiries in relation to these concerns.”
2024-0429-Response-from-Westmorland-Court-Care-Home.pdf ↗· Westmorland Court Care Home