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Investigation and inquest
On the 26th March 2019, I commenced an Investigation into the death of Sidney Clarence Baker, born on the 23rd June 1928. The Investigation concluded at the end of the Inquest on the 20th November 2019.
The medical cause of death was: -
Ia Bronchopneumonia
Ib Ischaemic Heart Disease, Cerebrovascular Disease, Lower Urinary Tract Infection
The Inquest conclusion was Natural Causes.
Circumstances of the death
Clarence Baker died on 24th March at the Royal Albert Edward Infirmary in Wigan. The circumstances of his death are as follows, Mr Baker was a frail elderly gentleman, who suffered from a number of co-morbidities, including Dementia, Chronic Kidney Disease, Type II Diabetes, Osteoporosis, previous bladder cancer and aortic aneurysms. As a consequence of Mr Baker’s poor health, it was deemed necessary to admit him to a specialist care facility in 2014. By December 2018, a decision was made to transfer Mr Baker's care to a nursing facility and he was assessed and secured a placement at Barley Brook care home on or around 23rd January 2019. During January to March 2019, Mr Baker had a number of unwitnessed falls, but did not sustain and physical injuries. A falls team referral should have been made by March 2019, but this did not occur. Mr Baker also struggled to eat and drink during this period which should have warranted a dietician’s referral but once again, one was not made. Due to Mr Baker's declining health, his GP surgery was contacted on or around 11th March 2019, regarding concerns about his general frailty, weight loss and Do Not Attempt Resuscitation. The surgery saw Mr Baker on 12th March 2019 and following an examination, diagnosed him as having a general deterioration in his health. Safety net advice was given and Mr Baker was then taken to hospital on 13th March 2019 following a fall at his care home. At hospital he was diagnosed and treated for acute kidney injury but his condition deteriorated and he died on the above date.
Coroner’s concerns
During the Inquest, evidence was heard that: -
1. There were no contemporaneous documents that a Dieticians or Falls Team referral had been made by the Care Home personnel in question
2. There were concerns that entries contained in Mr Baker's care plan were incorrect, including vital information contained on his weight monitoring sheet. Furthermore, the general quality of record keeping was poor.
I request that you undertake a review to ensure staff receive the appropriate training on the issues identified above.
Information checked against the published report and official responses