Lilian Bernadette BEHRENDT · Prevention of Future Deaths report

On 06/12/2021 I commenced an investigation into the death of Lilian Bernadette BEHRENDT aged 91. The investigation concluded at the end of the inquest on 19/05/2022.
The medical cause of death was:
1a) Bronchopneumonia
1b)
1c)
1d)
2 Aortic Valve Stenosis, Systemic hypertension
The conclusion of the inquest was: Natural causes. Mrs Behrendt developed symptoms of sepsis which were not identified and treated until shortly before her death.

On 28 November 2021 Mrs Behrendt did not appear well at breakfast although her observation recordings were within normal range. Mrs Behrendt's condition deteriorated throughout the day and at 13:49 hours 111 service was called. After further discussion the ambulance service was called at 15:38 by the 111 service. The call was incorrectly graded. The care home records continue to record Mrs Behrendt as being "content". Mrs Behrendt continued to deteriorate and the ambulance service was called again and the call was upgraded to a Category 2 call at 19:27 hours. The ambulance service arrived at 20:14 hours and Mrs Behrendt was taken to Queen Elizabeth Hospital where she was diagnosed with chest sepsis and was noted to be very unwell. Despite active treatment, Mrs Behrendt's condition deteriorated and she died later that evening.

1) The records relating to Mrs Behrendt referred to her as being “content” throughout the 28 November 2021 and did not refer to her deteriorating condition. There was no record of the result of the observations taken throughout the day or why these were taken, i.e. Mrs Behrendt’s condition was deteriorating and at the request of her family due to their concerns with regard to Mrs Behrendt’s poor presentation.
2) The evidence was that the Nurse taking the observations on 28 November 2021 did not have access to a mobile recording device, which staff are given to use at the Home specifically to record results, although she did have access to a computer on the Unit to input the information. Evidence was heard that the number of mobile recording devices has now increased to 12, which “should be adequate”, but that “they do get lost and broken”. As at the day of the inquest 10 were available to staff to use.
3) Evidence was originally heard that the Nurse in Charge had been “dismissed” following Mrs Behrendt’s death. At the inquest evidence was heard that “the probationary period had not been extended”. Evidence was heard that the nurse may not have been aware that she was required to record every action and it was accepted that the records in general were “abysmal”, namely those completed by other members of staff.
4) The Nurse in Charge had contacted another member of staff to comment on Mrs Behrendt’s general presentation as she [NIC] had not worked with Mrs Behrendt for over a month, having been placed on a different Unit.
5) It was unclear from the Home records whether a DNACPR and a ReSPECT form were in place. The Manager had not seen a paper copy and was unclear as to the position.
6) The evidence revealed a lack of ownership for overall running of the Home, with no one person having or taking responsibility and accountability for the residents, referring to, e.g. Nursing Lead being responsible for DNACPR, nurses “knowing” they should complete the results of observations taken and checking to see that action had been taken Downham Grange Care Home is a relatively small home with a maximum of 62 residents. At the time Mrs Behrendt was a resident the Home had in the region of 48 residents. She had been there since 2018 and the present Manager since May 2021. The Manager had little knowledge of Mrs Behrendt, knowing of her “in passing”.