Raymond JENNINGS · Prevention of Future Deaths report

On 28 March 2023 I commenced an investigation into the death of Raymond JENNINGS aged 84. The investigation concluded at the end of the inquest on 06 March 2025. The conclusion of the inquest was that:

Raymond (known as 'Ray') Jennings died on 07.03.23 at Huddersfield Royal Infirmary from pneumonia. There was a failure to promptly administer antibiotics by his care home but this was probably not causative in his death.

Raymond, an 84 year old gentleman was admitted to Huddersfield Royal Infirmary on 19th February 2023, He was diagnosed with sepsis due to community acquired pneumonia

Despite medication, Raymonds prognosis remained poor, he was put on palliative care on 24th February and sadly passed away on 7th March 2023

Ray Jennings lived at Abbey Place Care Home, 90, Abbey Road, Huddersfield HD2 1BB. He was physically frail and lived with Alzheimer's Dementia

Antibiotics for a chest infection were prescribed by Ray's out of hours GP on 16.02.23. The care home made initial attempts to obtain the antibiotics from a pharmacy that evening but failed to achieve this. They did not seek further medical advice or admission to hospital that night. Further unsuccessful attempts were made to obtain the antibiotics the next day. No attempts were made to obtain antibiotics on 18.02.23 nor was further medical advice or admission to hospital sought. By 19.02.23 Ray's condition had deteriorated to the extent that he required hospital admission.

Despite appropriate treatment in hospital, Ray did not recover and he died on 07.03.23. The medical evidence was clear that, although it could not be said that prompt admission of antibiotics would have probably prevented the need for Ray to be admitted to hospital and/or his death, the failure to either promptly administer the antibiotics or seek further medical care for him was a significant failing on the part of the care home. This was admitted in evidence and was identified as a missed opportunity.

Evidence was given by the care home that lessons had been learned and systems improved but no documents were adduced in support of this such that the court could be confident that this issue would not reoccur. For that reason this report is being issued, in particular in relation to the concern that there may be a future risk that other vulnerable residents may not have their need for the prompt administration of prescribed medications met.