Source · Prevention of Future Deaths

Frederick King

Ref: 2022-0363 Date: 15 Nov 2022 Coroner: Jenny Goldring Area: Berkshire Responses identified: 1 / 1 View PDF

The care home failed to ensure adequate fluid intake for the resident, particularly during hot weather, and maintained poor records. A critical lack of on-site management was also identified.

Date 15 Nov 2022

56-day deadline 10 Jan 2023

Responses identified 1 of 1

Care Home Health related deaths

Coroner's concerns

AI summary

The care home failed to ensure adequate fluid intake for the resident, particularly during hot weather, and maintained poor records. A critical lack of on-site management was also identified.

View full coroner's concerns

(1) Fred did not receive adequate fluid in the 2 days prior to his death (985 and 770 ml). There were also 10 days during August and September 2021 when Fred received less than the minimum level of fluid, he required namely 1200ml. This was in the context of very high temperatures in the week of his death.

(2) Inadequate record keeping in the Birchwood Care made it difficult to obtain the relevant records for the Inquest and the records obtained were incomplete for example in terms of what recording timings of fluid provision, whether pads were wet/dry and also family concerns regarding health were not recorded and conveyed.

(3) There was no manager on the ground of the care home in the 3 days prior to Fred’s death.

Responses

1 respondent

CQC Regulator / Inspectorate

30 Jan 2023 PDF

Action Taken

CQC conducted follow-up inspections of Birchwood Care Home after concerns were raised and rated the home as 'requires improvement' or 'inadequate' in several domains. They are keeping the service under review and will conduct another comprehensive inspection by August 2023, and will consider enforcement action based on the circumstances leading to the death. (AI summary)

View full response

Dear Ms Goldring Prevention of future death report following inquest into the death of Mr Frederick King. Thank you for sending CQC a copy of the prevention of future death report issued following the death of Mr Frederick King. Further to your report referenced above, we are writing to you with our response to the issues raised. At the time of Mr King’s death, Birchwood Care Home had a rating of good in the safe, effective, caring and responsive domains and requires improvement in the well led domain. Please see the link to the comprehensive inspection report published in June 2021:

52921ff46e19?20211030120000 In April 2022, prior to the conclusion of Mr Frederick King’s inquest, CQC conducted a further, focused inspection in response to concerns. Following this Birchwood Care Home was rated requires improvement in safe and inadequate in well led. Please see the following link to the report published 21 April 2022:

5ef34e6489db?20220426120000 During a follow up inspection conducted in July 2022, CQC rated Birchwood Care Home requires improvement in all domains. Please see the link to the report published 25 August 2022: HSCA Further Information Citygate Gallowgate Newcastle upon Tyne NE1 4PA

e5129b59e250?20220825120000 In your report you stated the following matters of concern:
• Mr King did not receive adequate fluids in the days prior to his death and on 10 days during August and September during a period of very high temperatures
• There was inadequate record keeping at Birchwood Care Home with regards to Mr King’s fluid intake and output and whether pads were wet or dry.
• There was no manager on the ground of the care home in the 3 days prior to Mr King’s death.

We sent an urgent letter to the provider West Berkshire Council to confirm CQC had received the regulation 28 report and asked them to set out in writing evidence of the actions they had taken to date following this death and any additional action they intended to take in response to the prevention of future death report. We received a detailed response from the provider. We are satisfied the provider has taken sufficient action according to section 6 of the regulation 28 report to mitigate risks to people and prevent future deaths. We are keeping the service under review and will be returning for a follow up comprehensive inspection to assess their progress by 25 August 2023. When services are rated requires improvement CQC requests an action plan from the provider to understand what they will do to improve the standards of quality and safety. We work alongside the provider and local authority to monitor progress and we continue to monitor information we receive about the service, which will help inform when we next inspect. At the next inspection of Birchwood Care Home the inspection team will assess whether the provider is meeting legal requirements under the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 as well as the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 (‘Regulated Activities Regulations 2010’) and the Care Quality CQC (Registration) Regulations 2009 (‘the Regulations’) which set out the essential standards of quality and safety that service users have a right to expect. In addition, we will consider the circumstances which led to the death of Mr Frederick King in accordance with our Enforcement Policy to determine whether we need to pursue criminal or civil enforcement action. Our civil enforcement powers include;
• Issuing a warning notice;
• Impose, vary, restrict or remove a condition from the provider’s registration;
• Suspend registration; or
• Cancel registration.

If you have any further questions or concerns, please do not hesitate to contact us on the above number.

Report sections

Investigation and inquest

On 19th November 2021, an Inquest was opened into the death of Frederick Robert Peter King aged 78 years old. A pre-Inquest review was held on 21st April 2022. The Inquest commenced and evidence was heard on 14th and 15th September 2022. The Inquest was adjourned part heard due to the unavailability of a witness due to ill health and the need to obtain replacement evidence. The evidence continued on 10th November 2022 and the Record of Inquest was completed. The conclusion was a narrative conclusion with a rider of neglect.

Circumstances of the death

Fred was a resident at the Birchwood Care Home in Newbury, Berkshire which was operated by the West Berkshire District Council. He had vascular dementia.

He was admitted to the Royal Berkshire Hospital on 8th September 2021 and died on 9th September 2021 of an Acute Kidney Injury caused by dehydration.

He did not receive adequate fluids in the 2 days prior to his death namely 985ml on 7th September 2021 and 770ml on 8th September 2021, when the recommended level for him was 1400ml, and the minimum level was 1200ml.

I made a finding of neglect in the particular circumstances of this case, namely his high level of dependency (he could not feed or take fluid himself), the hot weather with outside temperatures of 26-30 degrees, the family concerns about his health not being recorded as conveyed to staff in the days prior to his admission.

He was admitted to hospital on 8th September 2021 and given 3 litres of fluid, but he deteriorated and died on 9th September 2021. His death was contributed to by frailty and vascular dementia.

Action should be taken

I was informed during evidence and in submissions at the conclusion of the Inquest as follows:
• It was accepted that the record keeping had been inadequate. The data-keeping had been overhauled and there is now an electronic record system in place and no more paper records.
• There is now an electronic system in place for recording fluid intake called Nourish. This ensures that there are fluid targets. By virtue of a drop-down menu it requires timings for fluid given and whether pads are wet or dry.
• Complaints from families are recorded.
• Records are now audited by 4 different managers and fluid records are checked daily.
• There is also a full-time manager on the ground at the care home.

I am satisfied that steps have been taken to improve the record keeping and the monitoring of fluid. However these systems are only as good as the data inputted and the audits conducted, and this will need to be kept under review. I am therefore drawing the above matters to the attention of the Care Quality Commission, aware that there have been recent inspections and a report issued on 25th August 2022 and aware that there will be future inspections.

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2022-0363
Date of report: 15 November 2022
Coroner: Jenny Goldring
Coroner area: Berkshire

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: 10 Jan 2023.

Sent to

Care Quality Commission

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.