Christopher John Royal · Prevention of Future Deaths report

On 28 – 30th July 2014 I commenced an investigation into the death of Christopher John Royal, 67 years. The investigation concluded at the end of the inquest on 30th July 2014.
The conclusion of the inquest was
Cause of death -
1a Aspiration of stomach contents
1b Ischaemic heart disease

Conclusion – Natural causes contributed to by neglect

Mr. Royal was properly detained under a DOLS order, Mental Capacity Act 2005 which prevented him from leaving Baron’s Park Nursing Home. He suffered a cardiac event on 25 January 2013 and was found collapsed in his en-suite bathroom that evening. Staff attending to Mr. Royal from the Nursing Home but did not provide any, or any adequate First Aid. Paramedics were summoned but Mr. Royal was pronounced life extinct as CPR was unsuccessful.

1) Mr. Royal was on 15 minute observations. The observations were not carried out by a designated member of staff; there was no system in place; the recorded observations were unreliable and inaccurate; recordings were not made by the staff who had actually observed Mr. Royal. Consideration should be given to a more robust, safe and accountable observation system, and proper training and auditing to ensure this is in place and operating effectively.

2) Evidence was taken that the Matron did not have a valid First Aid Certificate at the time of this event; it had expired in 2011. There was evidence that the nursing home staff response to this medical emergency was inadequate and insufficient. One member of staff said although First Aid trained she did not feel competent to carry out CPR. First Aid training is essential in a Nursing Home environment, and there should be in place a proper system to ensure training is provided, updated, effective and understood. An annual system of review and/or appraisal may assist in the monitoring process and allow staff feedback and concerns reporting.

3) Matron said she regularly worked a 13.5 hour shift as it meant less travelling time as many staff lived a distance from the home. This length of shift may not be conducive to good health care and may have contributed to the poor care given that evening to Mr. Royal. Consideration should be given to whether shifts of this length are for the benefit of the residents or the staff, and if any perceived benefits outweigh any potential problems this type of shift pattern may create.