John Keith Edwards · Prevention of Future Deaths report

On 06/01/2017 I commenced an investigation into the death of John Keith Edwards, 64. The investigation concluded at the end of the inquest on 10.1.2018. The conclusion of the inquest was:
Accidental death contributed to by neglect

The deceased was 64 years of age and had a medical history which included down’s syndrome, heart pacemaker, dementia, Osteoporosis and celiac disease. He was admitted to Southwinds Care Home Burntwood for respite on the 1st October 2016. His falls risk assessment was poor. He suffered 2 slip falls on the 2nd and 3rd October 2016 and 2 seizures on the 3rd October 2016. No medical help was sought and thereafter he was largely wheel chair bound. Significant bruising was noted on the 8th October 2016. Subsequent documentation was retrospective and poor. An out of hours GP was called on the 13th October 2016. His symptoms were poorly relayed to the GP and he was told only about a suspected chest infection. He prescribed prophylactic antibiotics and advised urgent referral to his own GP. This was not done. There was no evidence of a skin care plan. District nurses were called in on the 24th October 2016 to attend to a significant pressure sore. He was found to be screaming in pain and with obvious deformity of lower limbs. He was admitted to Good Hope Hospital and diagnosed with an old left acetabular fracture, an old displaced right neck of femur fracture, bilateral pulmonary embolus, possible liver laceration, pneumonia, congestive cardiac failure , sacral and left thigh ulceration. The original fractures had occurred well before his admission to the home. However his subsequent rapid decline was due to a combination of the subsequent falls, seizures, reduced mobility and development of pressure sores in the home. He was discharged from the hospital to Hoar Cross Nursing Home Abbotts Bromley where he died at 22.41 hours on the 19th December 2016.

(1) Southwinds Care home did not appear to be able to cope with Mr Edwards complex care needs. Consequently the original placement appeared to be inappropriate
(2) The Care Home had an inadequate policy to deal with falls and no policy for pressure sore prevention and care
(3) Care Home staff applied a seizure policy which was not specific to the resident.
(4) Care Home staff failed to seek medical assistance following seizures.
(5) Care Home staff failed to deal with significant bruising which developed 8 days after admission to the Care Home.
(6) Care records were retrospectively filled in.
(7) Staff and management failed to recognise and seek help for the residents deteriorating condition other than by way of an out of hours attendance when the GP was given minimal information and the urgent follow up request was not done.
(8) Staff were unaware that medication brought in by the family was available to Mr Edwards, therefore it was not given. None was sought from the GP.
(9) Non patient specific dressings were used on pressure sores.
(10) A non-patient specific mattress was used on his bed.
(11) Visits by the placement officer and disability nurse failed to identify Mr Edward’s deteriorating condition.