Gloria SIMON · Prevention of Future Deaths report

On 23 September 2025 I commenced an investigation into the death of Gloria SIMON aged 81. The investigation concluded at the end of the inquest on 29 October 2025. The conclusion of the inquest was that:

On 9 September 2025 the Deceased moved into Riversdale Care Home, 14-16 Riversdale Road, West Kirkby, Wirral, to achieve some respite for family members who normally provided care for her at home. Her previous medical history included longstanding Chronic Obstructive Pulmonary Disease and Dementia.

On 17 September 2025 care home staff sought GP input following concerns about her health, but on learning this was not immediately available they did not seek clinical assistance through the 111 telephone line. None of the care home staff had any clinical qualifications. It is not clear that their training equipped them to deal with this situation appropriately. This resulted in an opportunity to secure timely clinical input being missed.

On 19 September 2025 staff were again concerned about the Deceased's health and took basic observations, which revealed very low oxygen saturations, noted to be 84%. An urgent referral to a different GP practice was made, but the GP to whom the case was allocated chose not to visit to assess the Deceased in person, having misread the 84% as 94%, and having failed to note or explore the previous medical history. Based upon his diagnosis of a probable chest infection, the GP prescribed antibiotics, which were administered, but the Deceased's condition deteriorated and she died at the care home the following day from natural causes.

The evidence did not reveal whether or not attendance by a GP (on either 17 or 19 September 2025), closer monitoring by care home staff or admission to hospital would have been likely to change the outcome.

On 9 September 2025 the Deceased moved into Riversdale Care Home, 14-16 Riversdale Road, West Kirkby, Wirral, to achieve some respite for family members who normally provided care for her at home. Her previous medical history included longstanding Chronic Obstructive Pulmonary Disease and Dementia.

On 17 September 2025 care home staff sought GP input following concerns about her health, but on learning this was not immediately available they did not seek clinical assistance through the 111 telephone line. None of the care home staff had any clinical qualifications. It is not clear that their training equipped them to deal with this situation appropriately. This resulted in an opportunity to secure timely clinical input being missed.

On 19 September 2025 staff were again concerned about the Deceased's health and took basic observations, which revealed very low oxygen saturations, noted to be 84%. An urgent referral to a different GP practice was made, but the GP to whom the case was allocated chose not to visit to assess the Deceased in person, having misread the 84% as 94%, and having failed to note or explore the previous medical history. Based upon his diagnosis of a probable chest infection, the GP prescribed antibiotics, which were administered, but the Deceased's condition deteriorated and she died at the care home the following day from natural causes.

The evidence did not reveal whether or not attendance by a GP (on either 17 or 19 September 2025), closer monitoring by care home staff or admission to hospital would have been likely to change the outcome.

1. The GP to whom this case was allocated told the court that he did not know that Gloria Simon was in a care home setting (as opposed to a nursing home setting), which had no clinical staff of any kind, despite having previously visited the premises and despite the clerical assistant's note on a Consultation Report that this was a request from VCH’. He indicated that it was as a result of this misunderstanding was that he did not visit the premises to make a face-to-face clinical assessment.

The court is concerned that a recurrence of this situation could leave vulnerable elderly patients with inadequate care. The court would like to know whether measures are being taken to ensure that those in the practice are properly informed about the nature and status of resident institutions with whom they have contact.

2. In its typed ‘Request for Care’ form, the care home noted that Gloria Simon's oxygen saturations were 84% and described them (correctly) as ‘very low’. The time when the observations were taken was not stated. Despite a clerical assistant at the GP practice having not done correctly that the reading was 84%, the GP misread the papers as saying 94% and described the oxygen saturations as ‘low’.

The GP told the court that he would have been assisted by knowing the patient's previous medical history and would have acted differently had he known it. However, the records indicate that this information had been supplied by the care home, had been flagged by another GP who made a record on the practice's system, and was available to him.

There was no evidence before the court to suggest that the GP had: (a) requested sight of the previous medical history, or made any enquiry about it when (or before) he spoke to a member of staff at the care home; or (b) asked when the observations had been taken or recommended that any further observations should be taken; or (c) asked about whether those observing or caring for the Deceased had any clinical qualifications (having assumed, incorrectly, that she was in a nursing home setting).

The court considers that this elderly vulnerable patient should have had a face-to-face clinical assessment but did not because of insufficient attention to detail and/or clinical curiosity on the part of the GP. The court would like to understand how the practice can ensure that this is not something that will recur.