Die like that - family
Bomb’ after great gran’s death
and compassion,” she said.
The LGSCO ordered the council to apologise to Mrs England in writing and pay her £500 for the distress she had been caused.
“It also had to pay Ann £250 for her trouble pursuing the complaint and explain what action it was taking to ‘to ensure its safeguarding enquiries are completed in a reasonable timescale and to the required standard’.
In spring 2018 Mrs England’s family began looking for a new home for her and she moved into Springfield Park Nursing Home in May that year.
“When we moved her, we did not think the care home could meet her needs, to be honest, but the difference was the manager was lovely,” said Ann.
“We thought we could go four times a day, it’s in Springfield Park, we can take her out for an ice cream, or a cup of tea, take her to the pub across the road to spend some nice quality time with her.”
She continued: “There were lots of things wrong.
We decided we would put up with that because we had been so brow-beaten and the council had not bothered that much we just felt ‘we can’t do it anymore, we just can’t do it.”
While the shortcomings at Springfield Park were obvious, the family enjoyed better relations with the staff and tried to compensate by helping as much as they could.
But in May 2019 health watchdog the CQC came in and ‘wiped the floor’ with the home - rating it as ‘inadequate’ and placing it in special measures.
“Mum was in the small unit upstairs. It wasn’t ideal, but we were managing,” said Ann.
“But when they moved her downstairs to this chaotic, horrible unit that was in absolute chaos. The staff didn’t know what they were doing.
“They moved all 11 people upstairs to downstairs. Fortunately they gave us a change of room and we made it as nice as possible. The rooms were awful.”
Ann’s sister, Susan Coates, said it also became ‘really apparent’ throughout her mother’s stay, that the home had ‘no idea’ how to manage her mother’s condition - particularly her seizures.
“We just thought, wrongly, that the social worker who was dealing with it and the home would ensure that this seizure management regime was in place with the care that my mother was getting,” said Mrs Susan.
The family raised concerns with the council after it became apparent that no seizure management plan was in place.
However, with the allocated social worker about to head off on holiday, it fell to Susan to draw up a workable plan, which was agreed by Mrs England’s GP.
The family says that, prior to this, there had been several episodes of serious failings in her mother’s care.
Describing one such incident, Ann said: “When I went in, the bed was laid flat, which it shouldn’t have been, she should always have been propped up. And she was choking on her own vomit and she was going blue.
“She was in this new room downstairs. I didn’t know where the emergency bell was, because nobody had shown me where the emergency bell was.
“I was rooting around, trying to get assistance off the staff. I went in the corridor screaming for someone to help me.
“I was trying to sit the bed up, but the controls on the bed were that badly worn I didn’t know which button was to raise the head or raise the feet.
“The staff came and assisted us to get her on her side and clear her airways. She got admitted to hospital.”
Mrs England’s care plan said that if she suffered a seizure 10 minute checks must be put in place until it has stopped. If the seizure continued for longer than 45 minutes, carers were to call the emergency services and tell her family.
On August 22, 2019, however, the ombudsman ers looked in on her at Y’s observations. Care 8.50pm, she had suffered a Worker C said they needed seizure and was vomiting. to contact Mrs Y’s family They called a ‘Nurse J’ who and she needed an ambuasked ‘Nurse K’ to check lance.” her observations. Ann explained : “In terms
However, according to of me going to the ombudsambulance service records, man, Rochdale council disthey were not called until missed all that, and yet it’s 9.43pm - nearly an hour in black and white. What later. those young girls told me
At 2am Ann went back to happened on that night the care home to get her happened, because it’s in mother’s medication chart. the report.”
Here Ann claimed she She added: “Rochdale was told by two ‘really council had that informaupset’ young carers tion, so why was it not -referred to as ‘Care Worker upheld by Rochdale counB and Care Worker C in the cil? Why? I don’t trust them ombudsman’s report - that one bit to safeguard anythey had been told not to body.” monitor her mother when ‘The council is accountathey came on duty at ble’ 7.30pm The Ombusdman report
“The care plan clearly adds that, given Mrs Engsaid if she’d had a seizure land ‘was vomiting and for we should monitor her all anyone knew at the time every 10 minutes. That could have been having a didn’t happen. The nurse seizure for more than 45 told them to go and look minutes, there was an after someone else,” said urgent need to call an Ann. ambulance. The failure to
“When they went back in do so was a fault, for which she’s dying and you think said. to mum she was choking on the council is accountable’. you are going to come up “This included a copy of her own vomit, she was Mrs England was taken and sit by her bedside and our comprehensive safeaspirating, she was choking to Fairfield Hospital and on tell her she’s not going back guarding procedures plan, on vomit and she wasn’t September 3 died in Rochto the care home because a meeting between the famwell. dale Hospice of aspiration they can’t manage her care ily and our director of adult
“They were insistent that pneumonia, having inhaled needs? social care, and details of he call an ambulance. - or ‘ aspirated’ her own “They’ve never been able our robust new allegation When you read that vomit. to manage her care needs. I management procedure. ombudsman’s report it’s The ombudsman found said you failed her. The sys“Our safeguarding poliquite clear that didn’t hapthat it seemed like she had tem has failed her. cies and procedures are pen. There was a delay.” aspirated while at SpringReflecting on what she regularly reviewed and
This account accepted in field Park. describes as a ‘horrendous updated and the safety, the ombudsman’s report, However, it was not posepisode’ she added: “I know wellbeing and protection of which states that ‘Care sible to say the outcome she is old and isn’t going to residents is a priority.” Workers ‘B’ and ‘ C’ told would have been any differlive forever and we all A Spokesperson for nurse K that Mrs England ent if not for the failings accept that. Beechwood Lodge said: needed an ambulance - but identified. Moreover, any “But you shouldn’t have “Beechwood Lodge is part he said he needed to check aspiration was ‘ likely to to die like this. You of a group with an excellent her first, they need to clean have occurred between shouldn’t have to be in a reputation that has been her and he would ‘sort it 8.05pm and 8.50pm when bed where you’re covered operating care homes for out’. there was no need for in vomit, they’re not calling over 30 years.
It also records how Care 10-minute observations’. an ambulance, it shouldn’t “We are immensely Worker ‘ C’ had checked The report adds that be like that.” proud of our brilliant caring Mrs England’s seizure man10-minute checks would Ann and Susan say they staff who work tirelessly to agement plan folder, which ‘not necessarily have prehave donated all the commake sure that residents are said to call an ambulance if vented’ Mrs England from pensation money paid by kept safe, healthy and well she had secretions after a aspirating. the council to charity, with cared for. fit. She showed this to Nurse Nevertheless, the council the last payment going to “We have since introK who ‘ignored’ her. was ordered to apologise to Rochdale Hospice. duced a new home manIt adds: “Nurse K said to Ann and pay her £400 in Claire Richardson, the ager who has done a fantasleave but Care recompense for her distress council’s director of stratetic job in implementing Worker C said and time pursuing the comgic commissioning (DASS), many improvements over she would stay plaint. said the authority had the last 18 months, includas she felt Ann said a social worker accepted and implemented ing processes and systems uncomfortable made contact with the famthe ombudsman’s recomto ensure that care is of the leaving Mrs Y ily and said she was going to mendations and reiterated highest quality. while she was visit Mrs England at Fair‘our apology to the family “We have always fully covered in vomit field Hospital. This was in for any shortcomings in sersupported residents and and ‘ how she order to tell her she would vices provided at the care their loved ones in raising was with her not be able to go to Springhome’. any concerns or combreathing’. Care field Park and would need a “Following publication of plaints, and continue to do so.”workerbtoldnursingplacement.theombudsman’sfindings S Nurse K he But it was made clear she we commissioned an indeelect Healthcare Group, needed to call would not be welcome. pendent report into our which runs Springfield Park the out of hours “I said no way are you original safeguarding invesNursing Home, did not GP service. coming up to sit at my tigation, and ensured each respond to a request for Nurse K said he mother’s bedside at 94 of its recommendations comment. The home is curwould do this years old,” said Ann. was promptly actioned and rently rated ‘Good’ by the after taking Mrs “They’ve just told her shared with the family,” she CQC.
“You shouldn’t have to die like this”
found that staff at Springfield Park Nursing Home failed to follow those instructions in the seizure report plan that was not in place.
According to a ‘likely scenario’ set out in the LGSCO report, at 7.24pm Mrs England was in bed having a seizure.
When the night shift took over at 7.30pm, checks should have continued every 10 minutes.
But she was not checked again until 8.05pm according to a ‘retrospective’ entry in her seizure monitoring chart made by a senior care worker.
This did not note her condition but the ombudsman found it ‘unlikely’ she was having a fit or vomiting at this time.
But when two care work