Care Home Health related deaths

Concerns summary Care home staff failed to perform routine blood sugar tests on a diabetic resident, delaying critical diagnosis. A lack of formal shift handovers also prevents timely escalation of deteriorating conditions.

Concerns summary An agency team leader disregarded clear instructions by providing inappropriate wound care, suggesting inadequate training on care limits and adherence to specialist medical advice for carers.

Concerns summary Nursing home staff repeatedly and incorrectly assessed a vulnerable patient's falls risk as low, indicating ineffective training in risk assessment and a failure to adequately refer to specialist falls teams.

Concerns summary A lower hospital admission threshold for patients with learning disabilities is required. Furthermore, doctor's discharge instructions and safety netting advice for non-medical care staff must be clear and actionable.

Concerns summary Unclear wound care instructions on hospital discharge and a lack of documented communication between the hospital and care home led to confusion. The care home also lacked an escalation policy for such unclear care plans.

Concerns summary Patients with two failed catheter insertion attempts are not being transferred to hospital promptly, creating a risk of delay in necessary medical intervention.

Concerns summary A GP's misreading of oxygen saturation levels and incorrect assumption about the care facility's status led to inadequate assessment. The GP also failed to review patient history or ensure timely observations.

Concerns summary Miscommunication about the care home's status led a GP to not visit. Care home staff lacked training on obtaining urgent clinical input when a GP declined and failed to consistently take, record, and act on basic patient observations.

Concerns summary Absence of clear policy for medication administration when hospital discharge letters are missing caused staff confusion, resulting in an opioid overdose and continued use of harmful medication.

Concerns summary A patient was removed from a soft food diet without proper assessment or documentation, and external food was not checked for suitability by care home staff, risking future deaths.

Concerns summary A care home failed to assess and implement bed rails for an unstable patient, despite family concerns, and also neglected to use a crash mat, resulting in a fall that contributed to her decline.

Concerns summary A resident sustained unexplained injuries, followed by deficient record-keeping, delayed medical advice after a fall, and conflicting evidence from the nursing home manager, indicating an ongoing risk to residents.

Concerns summary A care home admitted a resident with a history of aggression against policy, without proper clinical assessment. Staff lacked empowerment to challenge this decision and were inadequately trained in risk assessments and care plan creation.

Concerns summary There were inadequate Speech and Language Therapy assessments, significant gaps in staff training for Basic Life Support, first aid, and nutritional assessments, and catering staff were unaware of resident dietary restrictions, posing risks to resident safety.

Concerns summary Insufficient staffing levels in care settings, especially when staff are distracted, compromise resident safety by reducing direct supervision.

Concerns summary The care home provided misleading information on supervision levels and lacked formal induction periods, regular reviews for residents, and comprehensive updates to support plans and risk assessments.

Concerns summary Delayed and disorganised staff emergency response, including failures to promptly raise alarms or call 999, coupled with inadequate CPR due to a misunderstanding of Do Not Resuscitate orders, led to critical care gaps.

Concerns summary Poor documentation of an unwitnessed fall, delayed medical attention despite clear patient deterioration, and inadequate staff training contributed to missed opportunities for care.

Concerns summary A paramedic misinterpreted a ReSPECT form, believing it precluded resuscitation for choking, which may be a reversible event, raising concerns about form application.

Concerns summary The care home demonstrated a cultural problem of inadequate risk assessment and mitigation, with staff consistently failing to implement identified safety measures like securing bed rails.

Concerns summary The care home lacks effective staff training on falls risk identification, documentation, and mitigation, with assessments often missing professional counter-signatures and a clear falls prevention policy.

Concerns summary Widespread non-compliance with daily skin inspections, inadequate care plan updates, and delays in pressure ulcer management, compounded by poor record-keeping, led to a patient's deterioration.

Concerns summary Poor communication with family and power of attorney led to incorrect baseline information for discharge planning, misunderstandings among medical staff, and the failure to arrange a crucial follow-up appointment.

Concerns summary Care home record-keeping was inaccurate and incomplete, as observation scores after a fall were not consistently recorded, hindering proper assessment for escalation to medical services. The system remains unaddressed.

Concerns summary The care home delayed calling an ambulance for an unresponsive resident and maintained inadequate, inaccurate records, including misleading and unlabelled retrospective entries, compromising patient safety.