Source · Prevention of Future Deaths

Raymond Jennings

Ref: 2025-0125 Date: 6 Mar 2025 Coroner: Steve Eccleston Area: West Yorkshire Western 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner noted that the care home did not ensure a resident received prescribed antibiotics or further medical care in a timely manner, and lacked documented evidence of system improvements to prevent similar issues for other residents.

Date 6 Mar 2025

56-day deadline 1 May 2025 est. estimated from the report date

Responses identified 1 of 1

Care Home Health related deaths

Coroner's concerns

AI summary

The coroner noted that the care home did not ensure a resident received prescribed antibiotics or further medical care in a timely manner, and lacked documented evidence of system improvements to prevent similar issues for other residents.

View full coroner's concerns

Ray Jennings lived at Abbey Place Care Home, 90, Abbey Road, Huddersfield HD2 1BB. He was physically frail and lived with Alzheimer's Dementia Antibiotics for a chest infection were prescribed by Ray's out of hours GP on 16.02.23. The care home made initial attempts to obtain the antibiotics from a pharmacy that evening but failed to achieve this. They did not seek further medical advice or admission to hospital that night. Further unsuccessful attempts were made to obtain the antibiotics the next day. No attempts were made to obtain antibiotics on 18.02.23 nor was further medical advice or admission to hospital sought. By 19.02.23 Ray's condition had deteriorated to the extent that he required hospital admission. Despite appropriate treatment in hospital, Ray did not recover and he died on 07.03.23. The medical evidence was clear that, although it could not be said that prompt admission of antibiotics would have probably prevented the need for Ray to be admitted to hospital and/or his death, the failure to either promptly administer the antibiotics or seek further medical care for him was a significant failing on the part of the care home. This was admitted in evidence and was identified as a missed opportunity. Evidence was given by the care home that lessons had been learned and systems improved but no documents were adduced in support of this such that the court could be confident that this issue would not reoccur. For that reason this report is being issued, in particular in relation to the concern that there may be a future risk that other vulnerable residents may not have their need for the prompt administration of prescribed medications met.

Responses

1 respondent

Abbey Place Nursing Home

Other

Letter dated 17 Mar 2025 PDF

AI-classified response stance Action Taken

AI-generated response summary

• The home updated its medication policy to require staff to seek medical advice if out-of-hours/emergency medication is unobtainable within three hours. • The home implemented an electronic medication system and a digital care planning system to improve oversight and documentation. • The home changed to a single GP surgery and pharmacy for all residents and completed documentation training for all staff.

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Dear Mr Steve Eccleston, am writing in relation to the Section 28 report following the inquest of Raymond Jennings. This report requests that we write to you with what actions have been taken by the home to prevent this happening again. have detailed below the processes that have been completed and are in place: context we had not owned the home for a significant period when this incident occurred and were in the process of replacing the processes in place by the previous provider_ We have since this date fully implemented all our systems and processes into the home: Medication Policy have updated our medication policy which has been reviewed and sent to be signed by all staff this states that should a out of hours/emergency medication be prescribed and is either out of stock or unobtainable within 3 hours the team are to call for medical advice_ Electronic Medication System We have implemented an electronic medication system throughout the home; this system emails a report daily to the management and area manager with stock levels, missed medications or any other medication issues so they can have complete oversight; Care Planning System We have implemented a digital care planning system that improves documentation and provides real time analysis to ensure processes are monitored and all care is delivered. GP and Pharmacy Changes We have changed so that all residents use the same GP surgery and pharmacy this allows clear communication between the home and the designated organisations and builds a close relationship with them which has significantly improved the medication processes throughout the home_ Documentation Training We have completed documentation training with all staff since this incident to ensure record keeping is improved and accurate. Group For We home

hope this provides reassurance that we have taken the required steps to avoid a repeat of the tragic incident that occurred:. Should you require any further information please let me know Kind Regards Director WCG Abbey Ltd

Report sections

Investigation and inquest

On 28 March 2023 I commenced an investigation into the death of Raymond JENNINGS aged 84. The investigation concluded at the end of the inquest on 06 March 2025. The conclusion of the inquest was that: Raymond (known as 'Ray') Jennings died on 07.03.23 at Huddersfield Royal Infirmary from pneumonia. There was a failure to promptly administer antibiotics by his care home but this was probably not causative in his death.

Circumstances of the death

Raymond, an 84 year old gentleman was admitted to Huddersfield Royal Infirmary on 19th February 2023, He was diagnosed with sepsis due to community acquired pneumonia Despite medication, Raymonds prognosis remained poor, he was put on palliative care on 24th February and sadly passed away on 7th March 2023

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Report details

Reference: 2025-0125
Date of report: 6 March 2025
Coroner: Steve Eccleston
Coroner area: West Yorkshire Western

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 1 May 2025 (estimated from the report date).

Sent to

Abbey Place Nursing Home

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.