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Investigation and inquest
On 12 December 2023 I commenced an investigation and opened an inquest into the death of Alfred Edward SPARROW. The investigation concluded at the end of the inquest on 6 August 2024.
The conclusion of the inquest was that Mr. Sparrow “died from natural causes.”
Circumstances of the death
In answer to the questions “when, where and how did Mr. Sparrow come by his death?”, I recorded as follows:
“On 11.9.23 Alfred Sparrow, who lived with vascular dementia, became a resident at The Meadows Nursing Home, Catshill, Bromsgrove. During his time there, his oral intake of food and fluids would fluctuate, and he gradually became more frail. At the end of November 2023 his condition deteriorated significantly, and he declined and died there on the evening of 1.12.23.”
Coroner’s concerns
1) Mr. Sparrow had a longstanding diagnosis of vascular dementia, and his care plan stated that he required full assistance and support from staff at mealtimes with regard to his intake of food and fluids, and that he would not support himself if food and drink was placed in front of him. Despite the care plan, entries in Mr. Sparrow’s care notes, while recording his food and fluid intake, made no mention of whether a staff member at The Meadows Nursing Home was assisting him in this regard. Having heard the evidence at the inquest, I was satisfied, and found as a matter of fact, that staff at The Meadows Nursing Home did not always assist Mr. Sparrow with his food and fluid intake;
2) Furthermore, an entry in Mr. Sparrow’s notes purports to show that he was given, and drank 200ml of tea at 2030hrs on 1.12.23, some two hours after he had died. That entry was clearly false, and gave rise to a concern that staff might have been completing care note entries which did not reflect their actions in relation to Mr. Sparrow. If that is the case, then there is a clear concern that residents’ lives will continue to be put at risk by such actions;
3) The manager of The Meadows Nursing Home, ████████, gave evidence at the inquest that, at the request of the Care Quality Commission, she carried out an investigation into the events surrounding Mr. Sparrow’s death, and that she did so by looking at his care plan and care notes, and by speaking to staff who knew him. In her investigation, she failed to spot the false entry of 1.12.23 referred to above. Had she done so, her investigation would have identified at an early stage the deficiencies identified at 1) and 2) above.
Information checked against the published report and official responses