Care Home Health related deaths

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 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.

Concerns summary The report outlined the medical cause of death resulting from injuries sustained years earlier, but did not detail specific coroner's concerns for future death prevention.

Concerns summary Inadequate patient care involved poor assistance with food/drink, delayed referrals, staff neglect, incorrect incontinence assessment, and a critical failure to record opioid sensitivity across healthcare providers.

Concerns summary The care home lacked live CCTV monitoring for staircases, had no key fob access control, and no alarm if the stairgate was left open, creating unrestricted access to dangerous areas.

Concerns summary A patient was "lost to follow-up" for eight years after an incorrect diagnosis, highlighting a risk of future deaths if outpatient care is not consistently maintained.

Concerns summary Care home staff lacked a complete understanding of choking risks, and current procedures for visitors providing food are insufficient, failing to adequately protect at-risk patients.

Concerns summary Failures in care home included unreported falls, poor record-keeping, un-updated care plans, and staff inadequately trained in recognising patient deterioration and dementia care.

Concerns summary Nursing home staff were unaware of and failed to adhere to SALT recommendations for supervision and diet, resulting in missed re-referral opportunities and inadequate choking risk assessments.

Concerns summary A nurse lacked essential knowledge regarding appropriate CPR on flat surfaces and how to deflate patient mattresses during emergencies, posing a risk to patient safety.

Concerns summary Numerous failures in nursing home care included not seeking specialist advice, missing appointments, inadequate record-keeping, and poor recognition/response to deteriorating patient condition and insulin refusal.

Concerns summary The investigation into a patient's death was inadequate, failing to determine supervision levels, collaborate with manufacturers, identify incident cause, or properly assess equipment suitability.

Concerns summary The analogue Careline system caused significant delays for emergency services due to connection times, a single phone line, and key safe access issues, potentially unknown to residents.

Concerns summary The care home failed to revise mobility care plans despite documented deterioration and missed monthly reviews. They also failed to escalate concerns, like inability to weight-bear, to a GP or emergency services.

Concerns summary The care home lacked clear, robust policies for falls prevention and management, which were also not consistently understood or implemented by staff. This indicates a systemic failure in falls safety.

Concerns summary A high-risk falls resident sustained injuries due to an unplugged falls mat, unrecorded observations, and inadequate handover information for agency staff regarding critical safety measures.

Concerns summary The care home's pressure sore risk assessment tool (Braden Score) underestimates risk and creates confusion with a national standard, as it doesn't account for existing lesions and uses an inverse scoring method.

Concerns summary Carers' concerns were not escalated or recorded, and staff failed to appreciate the importance of incident reports for illness. Delays in calling emergency services occurred due to staff channelling medical issues through managers, who then underestimated the situation's seriousness.

Concerns summary The fire drills policy lacked safeguards to adequately monitor residents, especially those with dementia, before, during, and after drills.

Concerns summary Inadequate administration, documentation, and dispensation processes for medications, especially palliative ones, posed risks in the care home.

Concerns summary Nursing staff failed to use a fluid balance chart or monitor urine output, hindering detection of critical issues. A nurse was untrained in male catheterisation, and there was a general lack of understanding and training in managing long-term indwelling catheters.

Concerns summary A resident was unable to effectively use a call-bell due to potential unawareness of its portability or mobility limitations, highlighting a lack of consideration for alternative wearable alarm systems.