Omar Ahmed
22 Jul 2024 · Coroner Graeme Irvine · East London
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. failure to identify deterioration in living conditions and health
“Poor standards of communication between the domiciliary care company, the local authority and NHS trust resulted in a failure to identify the deterioration in Mr [name redacted] living conditions and health”
2. lack of clinical curiosity to predict harm
“Evidence heard in the inquest suggested an under-resourced and demoralised district nursing team lacked the clinical curiosity to predict the harm that would befall Mr [name redacted] should he be allowed to disengage from treatment”
3. lack of nutritious food and cleaning materials
“Mr [name redacted] poor decision-making in how he budgeted was never challenged, this led to a lack of nutritious food and cleaning materials in his home”
4. failure to address heating needs
“Mr [name redacted] unwillingness to turn on his central heating, a contributory factor in the development of his fatal condition -hypothermia, remained unchallenged at the time of his death”
5. misuse of care hours for non-care activities
“Domiciliary carers capitulated to Mr [name redacted] express wishes that they ought not assist him with cleaning, personal care or meals instead, state-funded care hours were utilised to assist Mr [name redacted] in attending his local pub and café”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“Since 2020 Ms [name redacted] had been provided with domiciliary care commissioned by the local authority. At the time of her death twice daily visits were undertaken. Ms [name redacted] was utilising state funded domiciliary care visits to deliver fast food to her home, no personal care was being provided.”
This report
“Poor standards of communication between the domiciliary care company, the local authority and NHS trust resulted in a failure to identify the deterioration in Mr [name redacted] living conditions and health.”