Care Home Health related deaths

Concerns summary No specific concerns were detailed in the provided text.

Concerns summary A personal alarm failed due to not being charged, indicating a flaw in the alarm charging and checking system for staff, which poses a significant risk if alarms are unusable during emergencies.

Concerns summary Fragmented inter-agency communication and a lack of clear discharge protocols led to a vulnerable patient being sent to an unsuitable care home. There was also no escalation process for medication refusal, exacerbated by a national bed shortage.

Concerns summary The care home's business decision not to use pendant call alarms meant fixed call bells were often out of reach for falls-risk residents, increasing their injury risk.

Concerns summary The nursing home failed to investigate a resident's fall, did not record a preceding fall or update the falls risk assessment, and provided misleading observation records, indicating systemic safety failures.

Concerns summary Concerns were raised about the proficiency of care staff in managing falls, specifically their interaction with ambulance services, accurate medical recording, and awareness of post-fall complications.

Concerns summary The care home failed to promptly report safeguarding incidents to the CQC, with notifications significantly delayed or entirely missed. Record-keeping was very poor, hindering staff's understanding of resident needs.

Concerns summary The care home could not adequately observe falls-risk residents during self-isolation due to staffing and lack of guidance. Vulnerable elderly patients sent to hospital alone faced significant communication barriers, hindering their care.

Concerns summary The care home failed to follow falls protocols, including not calling 999 after head injuries, delaying emergency services, and not updating care plans or identifying patterns in the deceased's repeated falls.

Concerns summary Care staff failed to address a heating fault during a heatwave and ensure adequate rehydration, leading to the patient's deterioration being unrecognised.

Concerns summary The patient was placed in an unsuitable care home, inappropriately discharged by the hospital despite warnings, and suffered an inpatient fall due to inadequate supervision and care for his confused state.

Concerns summary A care home failed to record and follow explicit instructions to contact a daughter during an emergency, leading to the resident being left unaided for hours after a fall.

Concerns summary Care home's "Post-Falls" policy lacked clarity on when to call emergency services for possible head injuries, and staff training on recognising intracranial injury was insufficient.

Concerns summary A care home failed to prevent a vulnerable resident from accessing plastic bags, despite staff awareness of self-harm risk, indicating a systemic failure in removing means of harm.

Concerns summary GP failed to recognise dehydration risk and document observations. Paramedics' national triage tool did not clearly mandate immediate transfer for sepsis. Care home staff lacked national guidance on recognising and escalating dehydration risks.

Concerns summary The care home lacked clear policy for handling hazardous personal property and a functioning sensor mat for falls detection. Observation protocols were unclear, and no rapid learning exercise followed the incident.

Concerns summary Residents with cognitive illnesses in independent living flats could leave the building unnoticed due to unlocked doors and lack of foyer observation. The environment was unsuitable for confused residents, posing a wandering risk.

Concerns summary The Commissioner failed to authorise essential 1:1 care for a patient at high risk of falls, despite it being the only identified method to mitigate her specific risks.

Concerns summary The care home suffered from poor documentation and observation quality, unclear Covid-19 infection control (no admission risk assessment), and staff confusion over PPE. Ambulance delays also impacted patient transfer.

Concerns summary Bed levers are improperly fitted by untrained staff without patient assessment, and policy gaps hinder reporting concerns. Miscommunication prevents trained professionals from fitting them, and there is a risk of supplying levers without essential safety straps for Divan beds.

Concerns summary Reduced information sharing from the care home to hospital clinicians, partly due to family visiting restrictions, hindered the provision of accurate baseline health data, risking treatment delays for vulnerable patients.

Concerns summary Data sharing and confidentiality rules prevented GPs from disclosing crucial risk factor information to care homes without consent, hindering safeguarding due to a lack of inter-agency sharing.

Concerns summary The care home failed to prevent residents with learning disabilities from accessing hazardous items, didn't escalate previous incidents, and lacked adequate night staff monitoring for wandering residents.

Concerns summary The absence of statutory international criminal background checks allows unsuitable individuals with foreign convictions to work with vulnerable adults and children, posing a significant risk.

Concerns summary The care home failed to conduct a robust investigation into a resident's fatal fall, missing crucial learning opportunities to prevent similar incidents for other residents.