James Robertson · Prevention of Future Deaths report

On 30th July 2015 I commenced an investigation into the death of James Robertson, age 84. The investigation concluded at the end of the inquest on 10th February 2016. The conclusion of the inquest was:
- Medical cause of death:
1a) Severe Coronary Artery Disease, Aortic Stenosis
2) Cerebrovascular Disease, Chronic Obstructive Pulmonary Disease,
Urinary Tract Infection
- Coroner's Conclusion at to death:
Death due to Natural Causes.

Mr Robertson died on 22nd July 2015 whilst resident at Cams Ridge Care Home, 7 Charlemont Drive, Fareham. He had last been checked in his room around 13.00 hours. When checked again around 15.30 hours, he appeared to be deceased. This was confirmed by attending paramedics at 15.50 hours.

1) At Mr Robertson's Inquest, his care notes were referred to and I was told that carers were not required to accurately report the time of carrying out checks on him. This meant the Inquest could not accurately ascertain when he had been checked by care staff on the day of his death.
2) I was also told that whether a resident at Cams Ridge was covered by DNACPR was indicated by a coloured sticker on the door of the resident's room and in centrally-located notes. The sticker on the door was not appreciated by a nurse who attended to him when he was found unresponsive and who then went to look in his notes, delaying resuscitation efforts. I was told that it would be better if DNACPR status was included on a resident's shift hand over notes which would be more quickly accessible than the centrally-located notes.
3) I was also told that there are no national standards for what should be included in emergency resuscitation packs kept at nursing homes and in consequence, the pack brought to assist Mr Robertson was lacking useful equipment, particularly a suction unit.