Care Home Health related deaths

Concerns summary Oxygen was incorrectly administered at a care home, with staff failing to recognise appropriate emergency oxygen levels and positioning. The clinical manager, a registered nurse, lacked training in oxygen administration.

Concerns summary The nursing home failed to adequately assess and act upon a resident's vulnerability to falls. Concerns were raised regarding the admissions policy, falls risk assessments, and associated staff training.

Concerns summary Faulty bedrail mechanisms led to instability, and staff provided inappropriate first aid after a patient's fall by moving her without assessing potential head and neck injuries.

Concerns summary The care home failed to update the care plan for a patient with a choking risk and left her unsupervised to eat after a 17-hour period without food, leading to choking and subsequent death.

Concerns summary Both a patient's hand-held buzzer and specialist bed alarm failed to alert staff when she got out of bed, resulting in a fall that was only discovered by hearing a 'thud'.

Concerns summary A patient's severe tibia and fibula fractures remained undiagnosed for four days despite regular medical visits, leading to extreme pain and contributing to her death.

Concerns summary A patient at a care home received five additional, unprescribed Dalteparin injections, with no clear explanation for their source or why they were administered.

Concerns summary Carers were not required to accurately log check times, delaying understanding of events. DNACPR status was not on shift handover notes, and the emergency resuscitation pack lacked essential equipment.

Concerns summary Cornwall care homes may lack adequate or updated policies for recognising and confirming death and for resuscitation, with staff often lacking awareness and proper training.

Concerns summary Staff lacked specific, prescribed training on how to properly conduct and record observations of residents.

Concerns summary Absent falls/bed rails assessments, incomplete care plans, poor record-keeping, inadequate night staffing, and informal handovers created significant safety risks due to unclear staff responsibilities.

Concerns summary Senior care staff lacked awareness of a resident's life-threatening condition and medication, failing to appreciate the urgency of re-ordering supplies. Care home records also lacked critical information about the condition.

Concerns summary Sub-optimal DVT prophylaxis, including delayed medication and missing mechanical treatment, was provided. Incorrect discharge instructions led to early cessation, and the nursing home failed to query excess medication.

Concerns summary Care home staff were unaware of the falls prevention policy, leading to inaccurate recording, delayed escalation of falls, and unreliable patient observation practices.

Concerns summary Significant failures in care home note-keeping, staff training, and communication led to delayed essential care. Procedures were performed unsafely and without adequate supervision or infection control.

Concerns summary The care home lacked a documented process for escalating incidents and concerns to trigger multi-disciplinary team meetings for reviewing vulnerable residents' risk assessments and care plans.

Concerns summary The care home lacked risk assessments and consent for wheelchair lap-belt use, and unclear guidance on their application raised concerns about unlawful restraint, contributing to a fall.

Concerns summary Care staff lacked training in PEG feeding, including patient mobility, leading to an incident of vomiting that was not reported or investigated, indicating systemic failures in training and incident management.

Concerns summary Care home staff lacked awareness and clear training on fall reporting policies and how to contact emergency services, indicating a need for regular, confirmed training.

Concerns summary The care home lacked a system for renewing deprivation of liberty orders, risking unauthorized detention. The absence of CCTV also hindered investigation into an absconding resident.

Concerns summary Significant systemic failures in care home staff training, including emergency protocols, resident observation, record-keeping, and handover procedures, alongside deficiencies in Out of Hours doctors' practices.

Concerns summary The care home failed to obtain a full prescription history from the GP, resulting in critical medications not being administered and creating a clear risk of harm to residents.

Concerns summary A pressure sore management plan was poorly followed, with falsified records, missed turns, and inadequately trained staff in record-keeping and mattress management. Referrals to specialists were also delayed.

Concerns summary A vulnerable patient was inappropriately placed in a residential care home without nursing care or staff trained for her needs. A lack of formal guidance for agencies led to unsuitable placements for vulnerable individuals.

Concerns summary Care home staff lacked training in head injury protocols and record-keeping, while safeguarding screening was insufficient. There's a systemic gap in monitoring high-risk residents when nursing care isn't deemed necessary, leaving them vulnerable.