Care Home Health related deaths

Concerns summary A child requiring 1:1 tracheostomy care died due to inadequate supervision and insufficient staffing, leading to a blocked tracheostomy. This represents a gross failure in care.

Concerns summary The nursing home's pre-transfer assessment process was inadequate, relying on incomplete documentation and lacking face-to-face evaluations, resulting in missed critical patient information.

Concerns summary Care home staff provided inconsistent information about a patient's condition and failed to initiate CPR for a potentially reversible cardiac arrest, indicating inadequate training and integrity issues.

Concerns summary Systemic failures include an under-managed care home using agency staff with language barriers, poor inter-agency communication, and severe overcrowding in hospital emergency departments causing treatment delays.

Concerns summary The care home failed to promptly obtain prescribed antibiotics or seek medical care for a deteriorating resident, and could not demonstrate improved systems to prevent reoccurrence of this significant failing.

Concerns summary Inaccurate care home records, failure to update falls risk assessments, and an inadequate post-falls investigation indicate a failure to learn from incidents and properly monitor patient deterioration.

Concerns summary A care home's flawed internal investigation into a patient fracture, lacking detailed guidance and staff training, prevented learning from the incident and future death prevention.

Concerns summary Care homes lack widespread knowledge and regulatory requirement for anti-choking devices, even for high-risk residents, creating an avoidable risk of deaths from choking.

Concerns summary A faulty emergency exit door, combined with staff's lack of awareness, inadequate alarm checks, and poor shift handover procedures, created significant safety risks for residents.

Concerns summary The care home had deficient policy management, poor staff understanding, and inadequate emergency response training. Internal investigations into adverse incidents were insufficient and performed by untrained staff.

Concerns summary Indications of prolonged neglect, including poor hygiene and infected wounds, prompted a safeguarding alert. However, the nursing home owner failed to investigate this to identify learning or assess ongoing risks to other residents.

Concerns summary The care home had ambiguous care plans, staff routinely failed to follow safety protocols, and handover documents were deficient and unaudited, indicating systemic failures in ensuring resident safety.

Concerns summary The care home exhibited inadequate fall reporting, ineffective patient monitoring, reliance on family for medical intervention post-fall, and poor, unsecured record-keeping, hindering proper resident care and risk assessment.

Concerns summary Care staff lacked consistent understanding and training on supervising a high-choking-risk resident, expressed low confidence in emergency first aid, and failed to apply professional curiosity.

Concerns summary Carers repeatedly failed to use a mandated transfer aid (Rotanda), contravening the care plan and previous instructions. This non-compliance resulted in improper patient positioning and injury.

Concerns summary A vulnerable patient was left without an accessible call bell, and care staff lack a checklist to ensure essential safety aids are consistently in place for residents.

Concerns summary Poor phone line quality and unclear communication from nursing staff hindered emergency calls. Additionally, a faulty resident call bell meant staff couldn't reliably be alerted, posing a significant safety risk.

Concerns summary Observations were consistently late or not performed at required intervals, indicating a failure to adhere to vital patient monitoring protocols in the care home.

Concerns summary The care home had outdated mobility plans, lacked falls minimisation plans for at-risk residents, and failed to meet call bell response times. These systemic issues were compounded by ineffective oversight and auditing.

Concerns summary Agency nurses were not provided with essential care home-specific training or policies, leading to an unsafe presumption they would know not to move a resident after a fall.

Concerns summary Inadequate night monitoring, including reliance on an insensitive video monitor, and poor medical record keeping compromised Mia's care. Lack of regular PEWS assessments and inconsistent specialist oversight were significant clinical governance concerns.

Concerns summary There's a lack of understanding in providing first aid for unresponsive patients and insufficient escalation of issues by care assistants, despite new policies not being fully embedded or known.

Concerns summary A lack of awareness regarding proper support for nursing bed mattress extensions poses a trapping risk if they detach. Furthermore, nighttime resident check procedures, though briefed, are not formalized into care home policy.

Concerns summary Inadequate monitoring and documentation of Mr Astley's nutrition and fluid intake led to severe frailty, highlighting systemic failures in care home record-keeping.

Concerns summary Systemic hospital capacity issues led to a patient waiting 22 hours in a corridor. Separately, a care home with existing safeguarding concerns failed to adequately monitor a resident's nutritional status and fluid intake.