Care Home Health related deaths

Concerns summary The care home had incomplete staff falls training, incorrectly categorised a high-risk patient as medium, and lacked a policy for reassessment following multiple falls.

Concerns summary Ineffective placement of pressure mats allowed residents to bypass them, and unreliable audible alarms meant falls went undetected by staff.

Concerns summary Unrestricted access and disposal of clinical examination gloves in care settings pose a risk, particularly for residents with cognitive impairment who can easily access them.

Concerns summary Multiple failures in multi-agency communication, inadequate staff training, and poor risk management regarding ligature use, patient observations, and resuscitation significantly compromised care for a patient with complex mental health needs.

Concerns summary CQC inspections fail to consistently include external premises areas routinely used by residents, risking overlooked safety issues outside the immediate care environment.

Concerns summary Inadequate bed rail safety was due to incorrect mattress use, poor staff training, absent risk assessments and policies, and delays in care plan completion. There was also a failure to inform families of medically relevant events.

Concerns summary Critical over-reliance on inadequately inducted agency nurses as senior staff led to unfamiliarity with essential policies, records, and patient care plans, resulting in medication errors.

Concerns summary Lack of communication and awareness between GPs and psychiatrists led to unsafe, duplicate prescribing and over-sedation of a care home resident with conflicting medications.

Concerns summary Care home staff lacked regular refresher training on policies and procedures. Inconsistent policies regarding medication refusal across different homes created confusion and potential risks.

Concerns summary There is a critical shortage of suitable long-term placements for individuals with complex mental health histories, causing persistent difficulties for social workers in finding appropriate facilities.

Concerns summary Care home staff lacked sufficient training in first aid for choking, assisting residents, and preparing appropriate foods for those with swallowing difficulties, compounded by inadequate management oversight.

Concerns summary A Health Care Assistant failed to perform first aid during a choking incident, and confusion over a DNA CPR order caused delays. The care home also failed to investigate or identify these critical issues internally.

Concerns summary There was an inadequate discharge and pre-assessment process between care homes concerning the requirement for subcutaneous fluids.

Concerns summary Care centres fail to prioritise dental hygiene and services, leading to potentially worsened conditions and lacking policies for managing missed appointments or identifying dental care needs.

Concerns summary The care home failed to implement adequate falls prevention, lacking care plans despite identified risks. Multiple falls were not properly investigated or reported, and patient safety was compromised by over-reliance on capacity.

Concerns summary The care home suffered from inadequate governance, untrained and insufficient staff, poor record-keeping, and ill-conceived changes that negatively impacted residents. Board oversight was grossly inadequate.

Concerns summary The nursing home had an inconsistent approach to falls prevention from wheelchairs, an over-reliance on staff intervention, and an inadequate post-incident investigation with unaddressed systemic issues and incomplete risk assessments.

Concerns summary Administration of anticoagulation medication after a head injury, advised by ambulance technicians, likely worsened an internal bleed and contributed to death.

Concerns summary Regular unsupervised communal areas in the care home led to resident injuries from falls, highlighting inadequate risk management and supervision arrangements.

Concerns summary Issues included inconsistent opioid handling, unaddressed statutory oversight for drug responsibilities, police failure to recognise safeguarding risks in medication errors, and a lack of statutory definition for "regular" medication checks in care homes.

Concerns summary Care home staff dishonesty regarding patient observations and GP calls, coupled with inaccurate records, indicated serious failures. Management surprisingly deemed the care reasonable despite these issues.

Concerns summary Care plans were inadequate, lacked specific risk issues, and were not appropriately reviewed or reassessed, either after incidents or as routine practice.

Concerns summary Falls risk assessments were not consistently followed, resulting in inadequate assistance and supervision for mobilising, and multiple preventable falls for the patient.

Concerns summary There were multiple missed opportunities to identify the deceased as a high falls risk, escalate care to the falls team, or implement falls prevention equipment and assessments.