Elsie Clarke
PFD Report
Historic (No Identified Response)
Coroner's Concerns (AI summary)
The report identifies a lack of staff training in calling emergency services or arranging GP visits, poor observation of residents, failure to report matters to the CQC, and inadequate record-keeping and handovers.
View full coroner's concerns
_ (1) There was an apparent lack of training for the staff at Hurst Hall in the appropriate use of calling either 999 or 111.
(2) The staff did not know how to arrange for the attendance of a GP for a resident who was not yet fully registered with a local GP. In particular appeared completely ignorant of the existence of a "Temporary GP Registration form (3) The level and quality of observation of the residents were very poor and did not include even some of the most basic issues such as whether the patient was warm, thirsty etc.
(4) There seemed to be a complete lack of understandingabout the legal requirement for prompt reporting of such matters as occurred in this case to the Care Quality Commission Kings 28th day they
(5) When a local GP was visiting another patient at the Home, the staff seemed unaware that could and should have asked that doctor to Iook at this patientlresident: (6) There was a complete failure to maintain food and hydration records There was a failure to keep proper and sufficient notes of the care afforded to each resident: (8) There was a failure to give full and effective "hand-over" at each shift change. (Numbers 1 to 8 above to be answered by Hurst Hall) (9) There was an obvious gap in the training of Out of Hours doctors in a number of aspects including (a) Keeping proper timed records of each attendance on a patient (b) Wearing or carrying a watch so as to be able to assess pulse rates, respiration rates etc. (c) Process for reporting deaths as necessary to the Coroner (10) The doctor advised the Home that in the present case there was no need to call the Coronerlpolice (numbers 9 and 10 to be answered by GTD Healthcare)
(2) The staff did not know how to arrange for the attendance of a GP for a resident who was not yet fully registered with a local GP. In particular appeared completely ignorant of the existence of a "Temporary GP Registration form (3) The level and quality of observation of the residents were very poor and did not include even some of the most basic issues such as whether the patient was warm, thirsty etc.
(4) There seemed to be a complete lack of understandingabout the legal requirement for prompt reporting of such matters as occurred in this case to the Care Quality Commission Kings 28th day they
(5) When a local GP was visiting another patient at the Home, the staff seemed unaware that could and should have asked that doctor to Iook at this patientlresident: (6) There was a complete failure to maintain food and hydration records There was a failure to keep proper and sufficient notes of the care afforded to each resident: (8) There was a failure to give full and effective "hand-over" at each shift change. (Numbers 1 to 8 above to be answered by Hurst Hall) (9) There was an obvious gap in the training of Out of Hours doctors in a number of aspects including (a) Keeping proper timed records of each attendance on a patient (b) Wearing or carrying a watch so as to be able to assess pulse rates, respiration rates etc. (c) Process for reporting deaths as necessary to the Coroner (10) The doctor advised the Home that in the present case there was no need to call the Coronerlpolice (numbers 9 and 10 to be answered by GTD Healthcare)
Sent To
- Hurst Hall Care Centre
Response Status
Linked responses
0 of 2
56-Day Deadline
15 Oct 2015
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 17/h February 2015 commenced an investigation into the death of Elsie Clarke dob October 1921. The investigation concluded on the 16th July 2015 and the conclusion was one of a narrative conclusion. The medical cause of death was Ia Bronchopneumonia,
Circumstances of the Death
Mrs Clarke was resident at Hurst hall care Centre and from the morning of 10th February 2015 she was developing a significant and ultimately catastrophic pneumonia: Opportunities were missed during the to summon medical help, which if called earlier might have led to a different outcome. She died later that day:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action.
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.