Linda Oldland

Coroner's concerns

AI summary

Hydon Hill Nursing Home failed to share critical patient information with medical staff, delayed antibiotic administration, missed a cardiac arrest, and incorrectly reported a DNAR, indicating policy and training deficiencies.

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The MATTER OF CONCERN is:

Hydon Hill Nursing Home:

- Did not pass on pertinent information to the GP about the positive dip stick test on 30 December 2021;
- Delayed the start of the stand-by oral antibiotics from the evening 31 December 2021 until Midday on 2 January 2022;
- Did not pass on pertinent information to the ambulance service on 2 January 2022 about Mrs Oldland’s wishes and the GP plan should she deteriorate with suspected sepsis;
- Did not recognise that Ms Oldland was in a state of cardiac arrest on 3 January 2022;
- Incorrectly informed the ambulance service that Mrs Oldland had a valid DNAR in place on 3 January 2022.

The Coroner considers that consideration ought to be given to updating policies and procedures in respect of the sharing and documentation of information relating to residents and/or in relation to training of clinical staff to address the above matters.

Responses

1 respondent

Leonard Cheshire Other

9 Oct 2023 PDF

Action Planned

Leonard Cheshire has implemented measures including manager's daily walkarounds, Sepsis training, and is reviewing their training program, service manager/staff induction, and implementing a quality audit plan, with plans to implement electronic care plans by March 2025. (AI summary)

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Dear Miss Crawford,

Re: Regulation 28 Report – Inquest into death of Linda Oldland concluded 3rd July 2023

The table below details the actions taken to ensure people living within a Leonard Cheshire facility are safe, following the sad death of Linda Oldland. I would also like to inform you of significant changes within the organisation over the last 12 – 18 months, which will have a beneficial impact on the safety of the people we support by further improving monitoring of quality and safety compliance:

• Executive team includes a new post of Executive Director of Quality and Clinical Care
• Restructure of Quality team with introduction of improved Quality Audit plan
• New Board of Trustees which includes Trustees with specific expertise in Quality and social care, and a new Chair of Board with extensive experience of the care sector. The new Chair has had a successful career as CEO and Chair in the Leisure and Hospitality sector. He is now chair for Ambitious about Autism, Nottinghamshire Trent University and St Christophers Hospice in South East London, as well as Leonard Cheshire. His focus is on the quality of services and financial sustainability in the charity sector. Since the death of Linda, we have implemented several measures to reduce the risk and we have further changes planned as detailed in the following action plan.

Action Impact Expected Completion

Manager’s daily walkaround The service manager’s now carry out a daily walkaround which is documented, following a standardised format. This ensures that they are visible, speak with staff and people being supported.

Completed Daily ‘flash’ meeting This is a 10-20 minute meeting held daily in the morning, chaired by the Service Manager/Deputy Manager or Nurse in Charge, its attended by key staff: Domestic, Maintenance, Activities, Nurses – at the meeting the daily activities are discussed along with any concerns regarding people using the service, changes in behaviour, signs of illness, external professionals visiting, GP contact

Completed Weekly clinical governance meeting These meetings are held with the clinical team, going into detail about clinical concerns within the service, any further support the people we support may need. Any visits from professionals and updates which have been carried out in the Completed

Founder: Group Captain Lord Cheshire VC, OM, DSO, DFC. Leonard Cheshire is a registered charity no: 218186 (England and Wales) and no: SC005117 (Scotland) and a company limited by guarantee registered in England no: 552847. VAT no: 899 3223 75. Registered office: 3 London Bridge Street, London, SE1 9SG. personal care plans or updates which may be needed.

Sepsis training We have implemented Sepsis training w/c 2/10/23 and all staff have a deadline of 30th Dec to complete.

30/12/23 Vital signs training We have sourced further information which will be given to all clinical staff currently in post and to all clinical new starters

30/11/23 Review of our training We are currently reviewing our training to ensure that we offer all necessary courses to meet the needs of people we support. Any courses we do not currently have, we either write them or source externally.

30/12/23 Reviewing Service Manager/Staff induction In order to ensure that staff and service managers feel valued and we improve our retention, and in turn our people are supported by a consistent team of staff who know their needs. 30/12/23 Implementation of quality audit plan Our quality team is changing and we are recruiting experienced quality and compliance specialists, they will follow an annual plan ensuring that each service is audited every 4 months, with the quality and operations teams working closely together to ensure that people we support are safe.

31/01/24 Implementation of electronic care plans This would give the business clear oversight, enable managers to review incidents, illnesses and trend concerns. This is a huge project and we are currently reviewing systems to ensure that we source the best one to meet our needs. 30/03/25

In addition to the action plan above, we have a robust handover process which is an opportunity to discuss any concerns the nurses and carers have with people, which people have a Respect document in-situ and who does not want to be resuscitated. Hydon Hill specifically have implemented an additional system to identify discreetly who does not want to be resuscitated, this ensures that if a person is not in their bedroom but around the home in their wheelchair, staff can easily identify them, should they need to.

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Investigation and inquest

An inquest into Ms Oldland’s death was opened on 21 January 2022. The inquest was resumed and evidence was heard on 30 September 2022, 3 October 2022 and 30 June 2023. The inquest concluded on 3 July 2023.

The medical cause of Ms Oldland’s death was:

Ia Sepsis. Ib Bilateral pyelonephritis. Ic Bilateral renal calculi treated with bilateral ureteric stents

The inquest concluded with a narrative conclusion as follows:

Ms Oldland was a 61 year old woman who lived at Hydon Hill Nursing Home, run by Leonard Cheshire. Ms Oldland had severe progressive multiple sclerosis and as a result she was bedbound and had minimal communication abilities. She also suffered from chronic kidney disease and kidney stones with bilateral ureteric stents, and a related history of recurrent urine infections. On 3 January 2022 Ms Oldland died at Hydon Hill Nursing Home. Her death was due to a urinary tract infection which infected both her kidneys and resulted in sepsis. Her kidney stones and ureteric stents contributed to her developing the urinary tract infection. On 31 December 2021 Ms Oldland’s GP from The Mill Medical Practice visited her at Hydon Hill Nursing Home. Given her history the GP thought she may be in the early stages of urinary sepsis. She therefore prescribed stand-by antibiotics to be commenced if Ms Oldland deteriorated, including by way of a reduction in consciousness levels. The GP also asked for Mrs Oldland to be admitted to hospital if she began to show signs of sepsis. This was in accordance with the wishes Ms Oldland had set out in her Proactive Anticipatory Care Plan (PACE). The GP also asked for a urine sample to be taken and delivered to the surgery for testing. During the consultation with the GP on 31 December 2021, the staff at Hydon Hill Nursing Home did not inform the GP that Ms Oldland had had a positive urine dip stick test the previous day. After the urine sample had been delivered to the GP surgery later that afternoon, staff at the GP surgery carried out a positive dipstick test before sending the sample off for further testing at the laboratory. Ms Oldland’s GP was not made aware of the second positive dip stick test. In the event that that Ms Oldland’s GP had been informed of either of the positive dipstick test results, Ms Oldland would have been immediately commenced on oral antibiotics and her life would have been prolonged, albeit it is not known what her ultimate prognosis would have been. On the evening of 31 December 2021, Ms Oldland’s consciousness levels deteriorated and from that point onwards until lunch time on 2 January 2022 there was a delay on the part of Hydon Hill Nursing Home in commencing the standby antibiotics.

In the event that the antibiotics had been commenced on 31 December 2021, Ms Oldland’s life would have been prolonged, albeit it is not known what her ultimate prognosis would have been. On 2 January 2022 Ms Oldland’s blood pressure deteriorated and staff at the nursing home called 999 and an ambulance attended from South East Coast Ambulance Service (SECAMBS). Ms Oldland was not transferred to hospital and discharged back to the care of her GP. Hydon Hill staff did not inform SECAMBS that Ms Oldland had had a positive urine dipstick test on 30 December 2021 and that the plan arising from the GP consultation on 31 December 2021 was for her to be admitted to hospital should she show signs of sepsis and that this was in accordance with Ms Oldland’s intentions as recorded in her PACE document. In the event that this information had been passed on to SECAMBS Ms Oldland would have been transferred to hospital and her life would have been prolonged, albeit it is not known what her ultimate prognosis would have been. Ms Oldland’s death was contributed to by neglect on the part of Hydon Hill Nursing Home.

Circumstances of the death

The circumstances of Ms Oldland’s death are as recorded in the narrative conclusion set out above.

In addition, the court found that on 3 January 2022, the day that Ms Oldland died, a nurse checked on her at approximately 13:00 and found her to be pale and unresponsive and called an ambulance. Whilst waiting for the ambulance the nurse reported to the telephone operator that Ms Oldland was breathing very slowly and had a weak pulse. As a result, life support measures were not implemented prior to the ambulance arrival. However, on the arrival of the ambulance paramedics found Ms Oldland to be cyanosed and in a state of cardiac arrest. They did not commence life support measures as they were informed by nursing home staff that Ms Oldland had a valid Do Not Attempt to Resuscitate (DNAR) form in place. Ms Oldland was declared deceased at 13:24.

The court found that Ms Oldland had in fact entered into cardiac arrest at some unknown point prior to the arrival of the ambulance crew. The court also found that Ms Oldland did not have a valid DNAR in place and her express wish, which had been recorded in her PACE form, was to be resuscitated in the event of a cardiac arrest.

It is of considerable concern that the trained nurses at the care home were unable to recognise that Ms Oldland was in a state of cardiac arrest. It is also a matter of considerable concern that staff did not know what Ms Oldland’s wishes were in the event of a cardiac arrest and therefore did not commence life support measures on 3 January 2022.

However, the court was not persuaded that life support measures would have materially improved Ms Oldland’s clinical course on 3 January 2022. Accordingly, the court was not persuaded that the absence of life support measures on 3 January 2022 contributed to Ms Oldland’s death.

Copies sent to

3. SouthEast Coast Ambulance Service (SECAMBS)4. The Mill Medical Practice 10 SignedANNA CRAWFORDAnna Crawford H.M Assistant Coroner for Surrey Dated this 14th day of August 2023

Inquest conclusion

Ms Oldland was a 61 year old woman who lived at Hydon Hill Nursing Home, run by Leonard Cheshire. Ms Oldland had severe progressive multiple sclerosis and as a result she was bedbound and had minimal communication abilities. She also suffered from chronic kidney disease and kidney stones with bilateral ureteric stents, and a related history of recurrent urine infections. On 3 January 2022 Ms Oldland died at Hydon Hill Nursing Home. Her death was due to a urinary tract infection which infected both her kidneys and resulted in sepsis. Her kidney stones and ureteric stents contributed to her developing the urinary tract infection. On 31 December 2021 Ms Oldland’s GP from The Mill Medical Practice visited her at Hydon Hill Nursing Home. Given her history the GP thought she may be in the early stages of urinary sepsis. She therefore prescribed stand-by antibiotics to be commenced if Ms Oldland deteriorated, including by way of a reduction in consciousness levels. The GP also asked for Mrs Oldland to be admitted to hospital if she began to show signs of sepsis. This was in accordance with the wishes Ms Oldland had set out in her Proactive Anticipatory Care Plan (PACE). The GP also asked for a urine sample to be taken and delivered to the surgery for testing. During the consultation with the GP on 31 December 2021, the staff at Hydon Hill Nursing Home did not inform the GP that Ms Oldland had had a positive urine dip stick test the previous day. After the urine sample had been delivered to the GP surgery later that afternoon, staff at the GP surgery carried out a positive dipstick test before sending the sample off for further testing at the laboratory. Ms Oldland’s GP was not made aware of the second positive dip stick test. In the event that that Ms Oldland’s GP had been informed of either of the positive dipstick test results, Ms Oldland would have been immediately commenced on oral antibiotics and her life would have been prolonged, albeit it is not known what her ultimate prognosis would have been. On the evening of 31 December 2021, Ms Oldland’s consciousness levels deteriorated and from that point onwards until lunch time on 2 January 2022 there was a delay on the part of Hydon Hill Nursing Home in commencing the standby antibiotics.

In the event that the antibiotics had been commenced on 31 December 2021, Ms Oldland’s life would have been prolonged, albeit it is not known what her ultimate prognosis would have been. On 2 January 2022 Ms Oldland’s blood pressure deteriorated and staff at the nursing home called 999 and an ambulance attended from South East Coast Ambulance Service (SECAMBS). Ms Oldland was not transferred to hospital and discharged back to the care of her GP. Hydon Hill staff did not inform SECAMBS that Ms Oldland had had a positive urine dipstick test on 30 December 2021 and that the plan arising from the GP consultation on 31 December 2021 was for her to be admitted to hospital should she show signs of sepsis and that this was in accordance with Ms Oldland’s intentions as recorded in her PACE document. In the event that this information had been passed on to SECAMBS Ms Oldland would have been transferred to hospital and her life would have been prolonged, albeit it is not known what her ultimate prognosis would have been. Ms Oldland’s death was contributed to by neglect on the part of Hydon Hill Nursing Home.

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