Mary Waldron
10 Jan 2014 · Coroner R Brittain · Coventry
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. unrecognised acutely unwell resident
“failure of the nursing home staff to recognise an acutely unwell resident”
2. inappropriate action after low blood pressure observed
“failure of the nursing home staff to undertake appropriate action when they were aware of the low blood pressure”
3. insufficient ongoing training on acute illness recognition
“lack of ongoing training with regard to the recognition and treatment of acutely unwell residents; with reliance solely on initial nursing training”
4. ineffective incident investigation by managers
“failure of the nursing home managers to undertake an effective investigation into this incident and to take action to prevent repetition”
5. misleading CQC report about protocol compliance
“inaccurate reporting by the nursing home managers to the Care Quality Commission (CQC) that internal protocols had been appropriately followed, when evidence given at the inquest was that this was not the case”
6. uncertain CQC investigation status
“lack of clarity as to the investigation that is to be undertaken by the CQC. The nursing home gave evidence that the investigation is closed, whilst the family believe it is ongoing”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“failure of the nursing home managers to undertake an effective investigation into this incident and to take action to prevent repetition”
Later report
“The serious incident investigation remained unallocated and with no timeframe for completion for over 7 months”
Closely relatedConfidence 0.90 · high
This report
“(1) failure of the nursing home staff to recognise an acutely unwell resident;”
Later report
“The inquest heard evidence that there was no clear system or expectation regarding the quality of checks on a resident who exhibited signs of being unwell.”
Responses
No published response was found on judiciary.uk.