Clive William · Prevention of Future Deaths report

On 22nd of October 2013 I commenced an investigation into the death of Clive William (DOB 31st October) who died on the 21st of October 2013 at Cae Glas, 82 Vale Street, Denbigh. The investigation concluded at the end of the inquest on the 20th of May 2013. The conclusion of the inquest was that the death arose from Natural Causes and the medical cause of death was Epilepsy Related to Parkinson’s Disease.

The Deceased had been a resident at Cae Glas Psychiatric Rehabilitation Care Home where he had passed away in bed on the 21st of October 2013.

(1) Evidence was given by the family of Mr Clinton that they had complained to the manager of the Care Home on several occasions about the standard of care which was being provided to Mr Clinton, namely that they would often find him drenched in urine and faeces, that his soiled bedding and clothing would be left in his room, that there were occasions when he would not receive his prescribed medication and that he would sometimes medical appointments which had been arranged for him.
(2) Evidence was also given by a representative of European Care who own the care home, confirming that although a complaints procedure exists within the organisation, the concerns of the family in this instance had not reached a senior level as should happen so that action could be taken.
(3) My concerns relate to the apparent failings of a complaints procedure in which staff can effectively withhold concerns from senior management and the lack of information within the care home that could advise persons with concerns as to how they may direct their complaints to a more senior level of management within the organisation. In the absence of a truly robust system of complaint, it is possible that concerns may not be addressed in a timely fashion or at all and could ultimately place residents at risk of harm.