Doreen Mattinson · Prevention of Future Deaths report

On 9 December 2015 I commenced an investigation into the death of Doreen Mattinson, aged 80 years. The investigation concluded at the end of the inquest on Thursday 14 April 2016. The conclusion of the inquest was that the medical cause of death was Bronchopneumonia and Pulmonary Embolus due to Carcinoma of the Left Lung. The conclusion as to the cause of death was that the death was from natural causes.

Doreen Mattinson became a resident of Acorn Care Home on 2 February 2015 when she had been assessed as not having the capacity to reside in sheltered accommodation.

On 7 July 2015 Hackney Social Services issued a Deprivation of Liberty Order due to her inability to make decisions about her accommodation, care or treatment as a result of her diagnosis of dementia. Other comorbidities included Chronic Obstructive Pulmonary Disease (COPD), Cerebrovascular Accident (CVA) and recurrent falls.

Her health remained stable until 27 October 2015 when she developed a cough. The GP attended Doreen Mattinson at the request of Acorn Care Home on six occasions between 28 October and 11 November 2015 due to concerns about the cough, and a possible CVA. She was initially treated with a nebuliser, given her COPD. When the cough had not improved by 11 November she was treated with antibiotics for a suspected chest infection.

On 12 November 2015 Doreen Mattinson deteriorated rapidly and with laboured breathing. The Clinical Manager, who is a registered nurse, attended Mrs Mattinson together with two Senior Health Care Assistants. The Clinical Manager administered oxygen at a 1 litre flow utilising a lifeline cylinder and mask.

(1) The London Ambulance Service attended Mrs Mattinson on 12 November 2015 and made a Safeguarding Report relating to the use of the oxygen. It had been reported that Mrs Mattinson had been lying supine on the bed saturating at 84% and struggling to breath. The oxygen could not be heard to be running and it was noted that only 1 litre was running when this should have been a15 litre flow with the mask applied.

(2)There was no recognition by the Clinical Manager or those present on 12 November 2015 of the level of oxygen to be used in an emergency situation or as to the importance of sitting the patient in an upright position.
(3)There was no evidence of training of the Clinical Manager, who was a registered nurse and the only member of staff on the residential unit on that day who would be expected to administer oxygen.