Margaret Elizabeth Greenacre · Prevention of Future Deaths report

On 1st October 2020 I opened the inquest into the death of Margaret Elizabeth GREENACRE, held a pre-inquest review hearing on 3rd November 2020 and heard the inquest on 10 February 2021.
Dr ████████ found the cause of death to be:
1a Aspiration Pneumonia
1b Immobility
1c Traumatic Haematoma of Right Leg
2 Frailty of Old Age
The conclusion of the inquest was:
Box 3: On 30 August 2020 the deceased suffered an unwitnessed fall at Baedling Manor Residential Care Home. She was taken to Northumbria Specialist Emergency Care Hospital and was found to have a traumatic haematoma to her right leg. She was transferred to Wansbeck General Hospital for continued monitoring. A fracture and intracranial injury had been excluded. She was initially prescribed antibiotics, but cultures did not identify an infection and were discontinued. The haematoma developed into a wound that required regular dressing. She continued to deteriorate and was receiving palliative care until her death on 18 September 2020 within Wansbeck General Hospital.
Box 4: Accident

Margaret Elizabeth Greenacre known as Betty was a resident at Baedling Manor Care Home having been admitted on 7th February 2019.
I heard that on 30th August 2020 Betty suffered an unwitnessed fall and was found in the doorway of her bathroom fully clothed with her underwear in place. Betty was taken to Northumbria Specialist Emergency Care Hospital and was found to have significant soft tissue damage to her lower right leg, but imaging excluded a fracture or intracranial injury. Betty was transferred to Wansbeck General Hospital. The wound developed and required regular dressing. Betty deteriorated and died within Wansbeck General Hospital on 18th September 2020.

1. On 4th September 2020 the Care Quality Commission received information from a whistle-blower regarding information of a safeguarding nature in that a service user had fallen and was taken to hospital having sustained a leg and head injury. This was confirmed to be Betty who died on 18th September 2020. Regulation 18 of the Care Quality Commission (Registration) Regulations 2009 provides that registered persons must notify the Care Quality Commission, without delay. The Care Quality Commission contacted Baedling Manor Care Home on 8th September 2020. Statutory notification was received at the Care Quality Commission on 12 September 2020. It is of concern to me that the Care Quality Commission were notified of concerns by a whistle-blower and, that statutory notification was not made until 12 days after the incident. It came to light during the inquest that an incident also arose in July 2020 but no reports have been submitted to date. It is of concern to me that matters are not being reported or are being notified late which may prevent incidents being investigated.
2. I have concerns with regard to the standard of record keeping at Baedling Manor Care Home, I am concerned that the care notes did not present an accurate picture of a resident and did not reflect what a resident was like and therefore what their needs were. It was accepted in evidence that the record keeping was very poor, the care plans were not changed or updated. In fact, upon the appointment of a new home manager, every resident’s care plan has been reviewed and updated. The information provided in the care plan contradicted the information provided in evidence and it appears staff may have had difficulty understanding Betty’s care needs for lifting.