Care Home Health related deaths

Concerns summary Severe staff shortages in the care home led to reduced contact time and checks for a vulnerable resident, contributing to an accidental fall and subsequent fatal complications from surgical treatment.

Concerns summary The care home failed to implement comprehensive falls prevention, with inaccurate reporting, poor escalation for frequent falls, and insufficient staff training and risk assessment for a resident with evolving dementia.

Concerns summary Clinically trained nursing home staff failed to assess DVT risk for an immobile patient, did not obtain preventative measures like TED stockings, and inadequately mobilized her post-discharge.

Concerns summary A care home failed to monitor a patient's food/fluid intake and observations, did not call emergency services for a high NEWS2 score, and had incomplete records, with no apparent actions taken after the death.

Concerns summary The hospital consistently fails to meet NICE guidelines for hip fracture surgery within the recommended timeframe, delaying early mobilisation and increasing patients' risk of complications like pneumonia.

Concerns summary A high-risk falls patient was inadequately protected by only one sensor mat. Furthermore, the incident investigation was unrecorded, and involved staff could not be identified.

Concerns summary There is a lack of specialist staff training in moving and handling individuals, especially regarding safe procedures after a fall.

Concerns summary Confusion between multiple agencies regarding care terms, funding, and provision led to a mismatch between Matthew's expected and actual care, hindering proper support for his complex needs.

Concerns summary A care home failed to promptly call an ambulance for a critically ill patient, maintained incomplete nursing and medication records, and staff lacked sufficient patient knowledge, indicating severe systemic failures.

Concerns summary Staff lacked training to immediately call emergency services and were not confident in basic first aid; emergency assistance calls were inefficiently routed, and no advanced first aider was on site.

Concerns summary Lack of continuous oversight, inadequate staff training in recognizing subtle signs of illness in the elderly, and poor documentation and communication within the care home created significant risks.

Concerns summary Inadequate wound care knowledge, poor documentation, and ineffective specialist referral pathways in a care home setting led to difficulties in charting wound progress and providing correct care.

Concerns summary Care home staff were unaware of crucial dietary requirements and other key information in resident care plans and risk assessments, leading to inadequate and potentially unsafe care delivery.

Concerns summary Sprinkler systems are not mandatory for care homes with residents of limited mobility, and these buildings aren't classified as 'Higher Risk Buildings' based on occupant vulnerability, leaving them at elevated fire risk.

Concerns summary The care home lacked qualified nursing staff for critical procedures like reinserting a RIG tube and employed staff with inadequate clinical judgment for critically ill residents.

Concerns summary Care home management demonstrated a significant misunderstanding of risk assessment processes, leading to inaccurate choking risk identification for residents, and staff provided ineffective CPR.

Concerns summary The care home failed to adequately prevent pressure damage for a vulnerable resident and identify their deteriorating condition. Frontline staff lacked crucial training, and senior management showed a culture of obfuscation.

Concerns summary The patient's mobility care plan was not updated to reflect increased observation needs, and staff progress notes inaccurately recorded the frequency of checks performed.

Concerns summary Care staff demonstrated a lack of clarity regarding escalation procedures for acutely unwell patients, the role of enhanced care teams, and accurate identification of Do Not Attempt Resuscitation (DNAR) status.

Concerns summary Supported housing showed a lack of clarity in their duty of care, failed to conduct agreed hourly checks, and did not follow procedures for drug checks or risk assessment updates. Welfare checks were inadequate due to staff shortages and poor escalation.

Concerns summary Poor record-keeping, especially during night shifts, obscured important resident events. The delivery of overnight care meant staff were often unaware of residents needing assistance, posing risks.

Concerns summary New Lodge Nursing Home lacked robust systems to ensure staff compliance with patient care plans, policies, and protocols.

Concerns summary The care home failed to update skin and mobility care plans, ensure regular repositioning, or recognise a deteriorating medical condition (cellulitis), leading to delayed medical assistance and an inadequate post-death review.

Concerns summary The care home failed to provide a disabled patient with a call alarm or adequate observations, lacked documentation for care plans, and did not properly assess or manage the risk posed by an aggressive resident, leading to an assault and neglect of head injury monitoring.