Source · Prevention of Future Deaths
Geoffrey Whatling
Ref: 2023-0418
Date: 27 Oct 2023
Coroner: Jacqueline Lake
Area: Norfolk
Responses identified: 0 / 2
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A care home failed to monitor a patient's food/fluid intake and observations, did not call emergency services for a high NEWS2 score, and had incomplete records, with no apparent actions taken after the death.
Date
27 Oct 2023
56-day deadline
22 Dec 2023 est.
Responses identified
0 of 2
Coroner's concerns
A care home failed to monitor a patient's food/fluid intake and observations, did not call emergency services for a high NEWS2 score, and had incomplete records, with no apparent actions taken after the death.
View full coroner's concerns
1. Mr Whatling was not eating and drinking very much. A food and fluid chart was not fully completed.
2. Emergency services were not called on 8 April 2023 when Mr Whatling scored NEWS2 7 as required.
3. The evidence so far revealed is that 111 call taker was not made aware Mr Whatling had scored NEWS2 7.
4. Mr Whatling’s observations were not taken hourly as required.
5. Some of Mr Whatling’s observations were recorded on a piece of paper and were not logged in his Care Records
6. The Manager only became aware of gaps in the records following concerns raised by the family.
7. There is no evidence that any action has been taken following Mr Whatling’s death.
2. Emergency services were not called on 8 April 2023 when Mr Whatling scored NEWS2 7 as required.
3. The evidence so far revealed is that 111 call taker was not made aware Mr Whatling had scored NEWS2 7.
4. Mr Whatling’s observations were not taken hourly as required.
5. Some of Mr Whatling’s observations were recorded on a piece of paper and were not logged in his Care Records
6. The Manager only became aware of gaps in the records following concerns raised by the family.
7. There is no evidence that any action has been taken following Mr Whatling’s death.
Report sections
Investigation and inquest
On 02 May 2023 I commenced an investigation into the death of Geoffrey Alan WHATLING aged 82. The investigation has not yet concluded and the inquest has not been heard. The medical cause of death was: 1a) Infective Exacerbation of Chronic Obstructive Pulmonary Disease 1b) 1c)
2) Frailty, Old Age
2) Frailty, Old Age
Circumstances of the death
Mr Whatling entered Amberley Hall Care Home on 14 March 2023 for rehabilitation. On 8 April 2023, concerns were raised by Mr Whatling’s family that he was unwell. At 17.37 Mr Whatling scored 7 on the NEWS2 requiring 999 call to be made. 111 was called. Further observations were carried out on 9 April 2023 (NEWS2 score 6), and 07.00 (NEWS2 score
5) and again on 10 April 2023 at 12.13 (NEWS2 score 9/10), when emergency services were called and Mr Whatling was admitted to Queen Elizabeth Hospital. Despite treatment Mr Whatling’s condition continued to deteriorate and he died on 26 April 2023. The medical cause of death is 1a) Infective exacerbation of chronic obstructive pulmonary disease 2. Frailty, old age.
5) and again on 10 April 2023 at 12.13 (NEWS2 score 9/10), when emergency services were called and Mr Whatling was admitted to Queen Elizabeth Hospital. Despite treatment Mr Whatling’s condition continued to deteriorate and he died on 26 April 2023. The medical cause of death is 1a) Infective exacerbation of chronic obstructive pulmonary disease 2. Frailty, old age.
Copies sent to
NOK : Department of Health Care Quality Commission (CQC) HSIB Healthwatch Norfolk NHS England & NHS Improvement
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Report details
- Reference
- 2023-0418
- Date of report
- 27 October 2023
- Coroner
- Jacqueline Lake
- Coroner area
- Norfolk
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 22 Dec 2023 (estimated).
Sent to
- Amberley Hall Care Home
- Athena Care Homes (UK) Limited