In September 2019 I commenced an investigation into the death of Eileen Pollard. The investigation concluded following an inquest on 28 February 2020 where the conclusion was:
• Natural Causes On 19 February 2019 Eileen Pollard died at hospital following a deterioration of her health conditions whilst resident in Buckingham Care Home, Penistone.

Overnight on 27-28 March 2019, Eileen Pollard, who was resident at Buckingham Care Home for respite care, became unwell with the symptoms of a myocardial infarction. She was taken to hospital by ambulance on 29 March 2019 where she passed away two days after her admission. During the course of her admission Eileen Pollard raised concerns about the fact that she had been pressing her nurse call bell which was not answered or was not working. The medical evidence presented at inquest was clear that even if this was the case, the outcome for Eileen Pollard would not have been any different.

I request that the organisation look again at the forms and documentation used to check call bells and reconsider whether these should be pre populated or blank to be completed contemporaneously with the check.