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Investigation and inquest
On 14th April 2022 Assistant Coroner Jonathan Stevens commenced an investigation into the death of ROSE MARY HOLLINGWORTH [age 83]. The investigation concluded at the end of the inquest on 26th July 2023. The conclusion of the inquest was of death by natural causes.
Circumstances of the death
ROSE HOLLINGWORTH was a frail lady with significant co-morbidities but was able to live in her own home because of package of care provided by HomeDotCare Limited, commissioned by Islington Social Services (London Borough of Islington).
In the morning of 3rd January 2022, a carer employed by HomeDotCare Limited came to ROSE HOLLINGWORTH’s home as part of the package of care but upon finding ROSE HOLLINGWORTH apparently asleep left the property (after discussing the situation with the staff at HomeDotCare on the phone) without carrying out any welfare checks or providing any care.
The carer returned to ROSE HOLLINGWORTH’s home later the same day and only then, when finding ROSE HOLLINGWORTH still in bed, did she undertake welfare checks and found ROSE HOLLINGWORTH to be unresponsive, breathing noisily and covered in vomit/haematemesis.
An ambulance was called and ROSE HOLLINGWORTH was admitted to Whittington Hospital where she died the following day, namely 4th January 2022.
The medical cause of death was established at the inquest to be:
1 (a) spontaneous intra-cerebral haemorrhage
2 Hypertension, Ischaemic Heart Disease, Chronic Obstructive Pulmonary Disease, frailty.
The inquest heard evidence from ████████, Consultant in Acute Medicine and General Internal Medicine at Whittington Hospital that ROSE HOLLINGWORTH had suffered a spontaneous catastrophic and un-survivable bleed and at no time would any medical intervention have been able to reverse that. Accordingly, even if the carer had carried out proper welfare checks when she came in the morning, and raised the alarm, it would not have affected the outcome in the case and ROSE HOLLINGWORTH would still have died.
At the inquest the following findings were made:
(i) There were significant failings in the care give to ROSE HOLLINGWORTH.
In particular:
a. The carer should have conducted a proper welfare check on her first care visit.
b. The carer should have been concerned that ROSE HOLLINGWORTH was not up and waiting for the arrival of the carer as she would normally have been.
c. The carer should have checked ROSE HOLLINGWORTH’S catheter bag, which was found later found to have 1-2 days of urine.
d. The carer should have made sure that ROSE HOLLINGWORTH took her medication.
e. The carer should not have been told by HomeDotCare when she called to leave ROSE HOLLINGWORTH and return at lunchtime.
f. The carer should have provided basic first aid at the scene.
(ii) The failings demonstrated a poor standard of care which in other circumstances could have delayed potentially lifesaving intervention and treatment.
(iii) The carer assigned on the 3rd of January 2022 was a Somali speaking carer who required a Somali translator in order for her to give evidence at the inquest, raising concerns that the carer lacked the ability to properly and safely communicate with ROSE HOLLINGWORTH in English when attending to her care needs.
Coroner’s concerns
(1) There was a failure to provide suitably trained, experienced and competent carers for a vulnerable person dependent on a package of care.
(2) There was a failure to properly supervise and manage the carers.
(3) The Care & Support plan was not properly completed and contained significant errors.
(4) There was a failure to properly monitor, review, manage and check the performance of the care agency.
Information checked against the published report and official responses