Mr Peter Antony Joseph Pearson · Prevention of Future Deaths report

On 14 December 2021 HMSC David Reid commenced an investigation into the death of Peter Antony Joseph Pearson, aged 78. The investigation concluded at the end of the inquest on 19th August 2022 which I heard. The conclusion of the inquest was that the medical cause of death was aspiration pneumonia and that Mr Pearson died from natural causes.

Mr Pearson died at the Worcester Royal Hospital on 6 December 2021 from aspiration pneumonia. Prior to his admission he had been a resident at the Corbett House Nursing Home, Droitwich Spa (“the Home”) from 26 November 2021. He was admitted to hospital on 5 December 2021 in a critical condition with erratic respiratory function and multi-organ dysfunction. He was known to suffer from moderate dysphagia amongst other conditions. The aspiration pneumonia was in all probability acquired whilst he was resident at the Corbett House Nursing Home.

(1) Mr Pearson’s condition on 5 December 2021 was such that his daughter asked the agency nurse on duty for an ambulance to be called at 12.30 pm. None was called until 6.10 pm. The nurse did not complete the nursing notes for the day from 5am onwards so there is no written record of Mr Pearson’s medical condition that day. Mr Pearson was found by paramedics alone in his room in a critical state. The staff on duty knew very little about him or his condition. No record of medications dispensed to Mr Pearson that day has been lost or is missing. He was found with medication in his mouth by paramedics. No records were kept of the checks of his oral cavity that were required to be undertaken twice a day. The Agency nurse has not been traced by the Home. The inquest found as a fact that the failure to call an ambulance earlier amounted to a missed opportunity.

(2) The former Registered Manager of the home at the time of the death is said by the Home’s owner, to be responsible for shortcomings in the management of the home including “providing false audit scores to senior management and cherry picking files which were presented for inspection”. It is accepted by senior management that there were “shortcomings” in oversight of this manager. The deputy manager (“DM”) at the time of Mr Pearson’s death has now been promoted to Registered Manager despite the fact that her job description as DM include responsibility for supervising and managing staff and ensuring that all medications were recorded.

(3) It is accepted on behalf of the Home that there was an “ineffective investigation” into Mr Pearson’s death by the Home. Responsibility for that cannot not solely be attributed to the former Registered Manager.

(4) Whilst there have been changes to audit practice, including the use of an external auditor it is not apparent that the oversight by senior management of the Registered Manager or DM has changed materially. Nor is it apparent what the current Registered Manager has done to date to improve record keeping and record retention and the supervision of nursing staff.