George Hulme · Prevention of Future Deaths report

On 27 June 2014 I commenced an investigation into the death of George Hulme date of birth 3rd March 1926. The investigation concluded at the end of the Inquest on 2nd December 2014. The conclusion was that the deceased died as a result of natural causes.

On 25th June 2014 Mr Hulme was assaulted by a fellow resident at Bamford Grange Nursing Home. He subsequently collapsed and required CPR. Ambulance staff from North West Ambulance Service attended the scene and requested the file relating to the injured person. The injured person was incorrectly identified and the wrong file was retrieved for another resident with a DNR in place. CPR subsequently ceased on the basis of the information on file.

1) Agency members of staff on duty did not have any information to assist with the identification of residents. Whilst a system of key cards was supposed to operate within the home, the agency staff on duty had no such card to identify residents.

2) Agency members of staff are supposed to have an induction and tour of the home upon their first visit. This did not take place adequately to sufficiently familiarise the staff with the residents or any method of correctly identifying residents.
3) An incorrect file was retrieved resulting in a potentially inappropriate treatment of an unconscious resident.
4) The residents’ rooms are not clearly marked internally or externally to denote who resides in the room giving rise to confusion over identification in the event of emergency treatment being required by an unconscious resident attended to by staff or medical practitioners not familiar with their identity.