Rachel Bernadette Johnston · Prevention of Future Deaths report

On 24/12/2018 I commenced an investigation into the death of Rachel Bernadette Johnston, a resident at Pirton Grange Nursing Home, Pirton, Worcs. ( Pirton Grange ). Holmleigh Care Homes Ltd. owns Pirton Grange. The investigation concluded at the end of the inquest 26th March 2021.
The conclusion of the inquest was as follows:
“On 26.10.18 Rachel Johnston, who had significant physical and learning disabilities, underwent necessary and extensive dental surgery under general anaesthetic. Having been discharged that evening back to Pirton Grange Nursing Home, Pirton, where she lived, she developed aspiration pneumonia which resulted in her being admitted as an emergency to Worcestershire Royal Hospital on 28.10.18, where she was found to have suffered an unsurvivable hypoxic brain injury. She was discharged back to Pirton Grange Nursing Home for end of life care, and died there on 13.11.18. Nursing staff at Pirton Grange Nursing Home failed to carry out adequate physiological observations on Rachel after her discharge following the dental surgery and failed to seek emergency medical assistance for Rachel from the evening of 27.10.18 when her condition clearly required it. Had emergency assistance been sought for Rachel at that time, she would probably have survived, and not have died when she did.”
Rachel’s medical cause of death was:
1a cerebral hypoxia
1b aspiration pneumonia
1c dental extractions
2 hydrocephalus and epilepsy following childhood meningitis.

see above.

(1) Following Rachel’s death, there appears to have been no adequate internal investigation or disciplinary procedure which was able to identify the gross failings of the nurses mentioned above. Accordingly, both nurses continued working at Pirton Grange for some time, without any action being taken to ensure that patients were not put at risk by their actions. Furthermore, no effort was made to report the conduct of the nurses concerned to the Nursing and Midwifery Council ( NMC ), the appropriate regulatory body, until February 2021, over 2 years after Rachel’s death;

(2) Even now, there appears to be no Policy in place at Pirton Grange which sets out a suitable and robust procedure for:
(a) identifying and investigating possible misconduct by nursing staff, e.g. where they have ignored a Policy;
(b) imposing an interim suspension on a member of the nursing staff, pending the completion of such an investigation, if in the interests of ensuring the ongoing safety of residents;
(c) if appropriate after the investigation has been completed, ensuring that member of the nursing staff does not work at Pirton Grange again; and
(d) if the internal investigation has identified likely misconduct, reporting that member of the nursing staff to the NMC.