Doreen Wilkins · Prevention of Future Deaths report

On 4th July 2017, Alison Mutch OBE, Senior Coroner for Manchester South, opened an inquest into the death of Doreen Wilkins who was aged 78 when she died in hospital. The investigation concluded at the end of the inquest which I heard on 10th November 2017.

The conclusion of the inquest was that Mrs Wilkins died as a consequence of a choking incident at home, following a routine care visit which did not last for its full duration. The evidence heard at the inquest did not establish whether or not Mrs Wilkins’s death would have been avoided had the care visit lasted for its intended duration. At the end of the inquest, I recorded a Narrative Conclusion to this effect.

Mrs Wilkins had been in receipt of a home care package provided by Comfort Care and commissioned by Tameside Metropolitan Borough Council since 2014. In summary, the care package consisted of 4 daily visits by a carer to provide assistance with personal care, monitoring of medication use and food and fluid intake, and encouragement with eating and drinking. Whilst these visits originally were each intended to last for 15 minutes, Mrs Wilkins’s care package was increased so as to include 30 minute care visits at breakfast, lunch, and teatime, with a 15 minute evening attendance.

The evidence before the court was that whilst concerns subsisted about the adequacy of Mrs Wilkins’s calorific intake, there were no previous documented problems with her ability to swallow food safely.

On 23rd June 2017, the teatime visit was undertaken by the Comfort Call carer who habitually visited Mrs Wilkins at that point in the day. The carer prepared food for Mrs Wilkins, but did not remain with her for the full 30 minutes duration of the care visit commissioned for her. According to her evidence, the carer stayed for around 20 minutes.

In the course of the inquest I heard evidence to the effect that Comfort Call carers’ visits are scheduled in blocks via rotas which do not always allow for travel time between scheduled visits. The matters of concern arising from this are as follows:

1. An absence of any travel time allowance in such circumstances may cause a carer to arrive late for a time critical care visit (such as one where a client is to be supported with regular medication);
2. A carer may cut short his / her visit to one client to enable them to arrive at their next scheduled appointment on time;
3. In circumstances where a carer is cutting short a visit, the client in question does not receive the duration of care they have been assessed as requiring (or indeed which Comfort Call Ltd has been paid to provide).

It is observed that Comfort Call Limited’s registration with the Care Quality Commission is contingent inter alia upon a requirement that the registered person must submit on the first day of every month to CQC a report showing:

“The actions that have been taken to ensure staff rotas are meeting the needs of service users including time critical calls and travel time between visits”.