Mr Peet according to the evidence heard at the inquest was placed at Acer Mews Care Home. His care according to information from his family was provided at a cost of approximately £10,000 a week. This was because he required 24/7 one to one care in a nursing home setting because of the extent of his needs including management of his tracheostomy tube. The inquest heard that at the home there were 2 units, with one registered nurse allocated to each unit. The remainder of the staff were Health Care Assistants. On the day of his admission to hospital the nurse trained in tracheostomy management decided not to cover the unit Mr Peet was in even though there were 3 patients requiring support with tracheostomies on that unit. Instead, they chose to work on the other unit. This left a nurse untrained in tracheostomies on that unit. It was unclear why there was no management oversight of this decision and what steps were in place at the time to avoid such a situation arising. The inquest was also told that the agency nurse used on the day did not have log in rights to the electronic systems in place at the home including the medication system. It was indicated that the manager at the time was aware of this and that it was likely that the nurse could as a consequence only make entries under the details of the other nurse. During the course of the inquest, it was difficult to unpick who had made certain entries. Even though Mr Peet was on one-to-one care and those involved could have no other residents to write up during the time they were caring for him the overall quality of the notes was extremely poor. Entries were limited and it was impossible to fully understand from the notes what had been observed and what had happened and at what point.