Mr Charles Knapp · Prevention of Future Deaths report

The inquest into the death of Mr Charles Knapp was opened on 14 March 2018. It was resumed on 17 June 2019 and the conclusion was handed down on 18 June 2019.

The medical cause of Mr Knapp’s death was:

1a. Aspiration pneumonia
1b. Paraplegia
1c. Spinal Injury sustained in 2008

2. Pressure Sores

The inquest concluded with a narrative conclusion, which is set out below.

In 2008 Mr Knapp suffered a spinal cord injury, the cause of which is unknown, which left him paraplegic. Mr Knapp was at high risk of developing pressure sores due to his immobility and incontinence and required assistance with all aspects of daily care. He lived alone at his home address and was in receipt of a package of care which was funded by Surrey County Council and provided by Angel Solutions UK Limited. On 1 December 2017 Mr Knapp was found to have two necrotic pressure sores, which had developed primarily as a result of sitting in his wheelchair and contributed to by an omission on the part of his carers to maintain his personal hygiene and to regularly reposition him. They also omitted to seek medical attention for the pressure sores. On 12 December 2017 Mr Knapp was admitted to East Surrey Hospital as a place of safety due to concerns about the care he was receiving at home. On 24 February 2018, whilst at the hospital, he developed Aspiration Pneumonia to which he succumbed later that day. The pressure sores caused him pain and led to him eating and drinking in a non-upright position, which contributed to the development of the Aspiration Pneumonia.

(i) Angel Solutions (UK) Ltd omitted to maintain Mr Knapp’s personal hygiene or regularly reposition him, and thereafter omitted to seek medical attention for the pressure sores. These omissions contributed to the development of the pressure sores and to Mr Knapp’s death.
(ii) Angel Solutions (UK) Ltd did not always provide Mr Knapp with two carers, despite his care plan requiring two carers to be present in order to move him and otherwise effectively care for him.
(iii) Angel Solutions (UK) Ltd failed to provide the court with a full set of Mr Knapp’s records, and as such the court did not have the opportunity to review the records for the key period prior to the development of the pressure sores.
(iv) Angel Solutions (UK) Ltd failed to supply the court with the full name and contact details of the main carer who was responsible for Mr Knapp’s care and as such the court did not have the benefit of hearing from her. Further, her surname had been redacted from the records which were left at Mr Knapp’s house.

The Coroner understands that although Angel Solutions (UK) has now been rated as inadequate following an inspection carried out by the Care Quality Commission in March 2019, it continues to provide care to approximately 8 individuals. The Coroner is concerned that there is a risk that the company will provide inadequate care to those individuals and keep inadequate patient records in respect of them, which gives rise to the risk of future deaths.