Frederick Robert Peter King · Prevention of Future Deaths report

On 19th November 2021, an Inquest was opened into the death of Frederick Robert Peter King aged 78 years old. A pre-Inquest review was held on 21st April 2022.
The Inquest commenced and evidence was heard on 14th and 15th September 2022. The Inquest was adjourned part heard due to the unavailability of a witness due to ill health and the need to obtain replacement evidence. The evidence continued on 10th November 2022 and the Record of Inquest was completed. The conclusion was a narrative conclusion with a rider of neglect.

Fred was a resident at the Birchwood Care Home in Newbury, Berkshire which was operated by the West Berkshire District Council. He had vascular dementia.

He was admitted to the Royal Berkshire Hospital on 8th September 2021 and died on 9th September 2021 of an Acute Kidney Injury caused by dehydration.

He did not receive adequate fluids in the 2 days prior to his death namely 985ml on 7th September 2021 and 770ml on 8th September 2021, when the recommended level for him was 1400ml, and the minimum level was 1200ml.

I made a finding of neglect in the particular circumstances of this case, namely his high level of dependency (he could not feed or take fluid himself), the hot weather with outside temperatures of 26-30 degrees, the family concerns about his health not being recorded as conveyed to staff in the days prior to his admission.

He was admitted to hospital on 8th September 2021 and given 3 litres of fluid, but he deteriorated and died on 9th September 2021. His death was contributed to by frailty and vascular dementia.

(1) Fred did not receive adequate fluid in the 2 days prior to his death (985 and 770 ml). There were also 10 days during August and September 2021 when Fred received less than the minimum level of fluid, he required namely 1200ml. This was in the context of very high temperatures in the week of his death.
(2) Inadequate record keeping in the Birchwood Care made it difficult to obtain the relevant records for the Inquest and the records obtained were incomplete for example in terms of what recording timings of fluid provision, whether pads were wet/dry and also family concerns regarding health were not recorded and conveyed.
(3) There was no manager on the ground of the care home in the 3 days prior to Fred’s death.