The Peterborough Evening Telegraph
Death in care: coroner verdict
Aformer resident of The Elms Care Home in Whittlesey died from natural causes, an inquest has found. Margaret Canham, 97, was a resident at the home operated by national care provider HC-One for most of the last year of her life.
She died from sepsis at Peterborough City Hospital
on 23 February 2019, just over a week after she left the home.
In the years since, The Elms has closed down after being rated Inadequate by the Care Quality Commission (CQC) and Cambridgeshire County Council (CCC) has suspended admission to all HC-One homes.
The national provider operates almost 300 homes across the UK.
Coroner Caroline Jones said in her conclusion that the timeline between Mrs
Canham exhibiting symptoms and being taken to hospital was “not inappropriately protracted” and that it’s not possible to say that her outcome would have been any different if she was admitted sooner.
But, she said, Ms Canham received a “suboptimal level of care” in her final days and there were “red flags that should have been further investigated” sooner than they were.
While accepting that HC-One have since changed
some of their practices, she also identified “shortcomings” with them at the time.
It was not always clear who had recorded what and when at the home, she said.
Earlier in proceedings she also confirmed she had concerns around sepsis management and the training and guidance provided in relation to it.
Speaking before the inquest’s conclusion, Mrs Canham’s granddaughter Kim Arden said: “My nan was failed and if something’s not done there’ll be other
lives lost.”
She also said that she doesn’t want anyone else to go through the “hell” she has been through and that CCC and the CQC “let us down”.
Senior area director for HC-One, Jonathan Richards, also spoke at the inquest to update Ms Jones on HCOne’s practices since Ms Canham’s death.
He said the whole company has moved to an electronic system for recording medication and that patient records are now kept centrally at homes rather than in patient’s rooms.
Staffing occupancy now also depends more on the levels of residents’ dependency rather than the number of residents, he added.
But he also confirmed that staffing levels didn’t change at The Elms between Mrs Canham’s death and its closure more than two years later and that it’s not possible for him to see whether staff were up-to-date on Sepsis training at the time.
Mr Richards was an employee of HC-One but was not senior area director at the time of Mrs Canham’s death.
Expert witness Dr Jane Douglas also provided evidence at the hearing, telling Ms Jones that Mrs Canham appeared to have received a “lack of attention to her care and support” in her final days at The Elms.
Dr Douglas, who reviewed Mrs Canham’s care in the period leading up to her admission to hospital, said that there was a “failure” to “recognise and respond appropriately” to the “soft signs of deterioration” she exhibited.
She said it was not possible for her to say whether Mrs Canham’s outcome would have been different had the home acted faster, but that she would have had an “increased possible chance” of recovery as early detection is vital to treating sepsis.
Her care was ultimately “not safe and effective” and “not at a reasonable standard”, Dr Douglas said, and there were “missed opportunities” to intervene.
It was “hard to establish” a picture of what was happening because there were limited handover notes and poor coordination between different records, she added.
Mrs Canham’s granddaughter said she was “pleased” with the outcome of the inquest.
Kim Arden said it was a “pleasant surprise” that the coroner Caroline Jons returned a longer conclusion than simply “natural causes”, noting that Mrs Canham died from a “community-acquired infection”.
In reaching her conclusion, Ms Jones had “taken a lot on board of what we’ve been saying”, Mrs Arden said – referring to herself and the families of two other former Elms residents who died at a similar time to Mrs Canham.
Inquests into the deaths of two other residents, George Lowlett and David Poole, are ongoing.
“We’ve never said they’re Peter Pan and they’re going to live forever, but when they needed medical assistance it should have been at the point of needing rather than delaying,” Mrs Arden said.
She added that she “had to” advocate for her grandmother because Mrs Canham was a woman who “never let anybody down”.
“She loved her family, her children, her grandchildren and great-grandchildren,” Mrs Arden said. “She was a family woman. She would never let anybody down, which is why I had to do what I’m doing.”
But Mrs Arden says that the last four years have been “a battle” to get to where she is and that she’s still “angry” with HC-One, which continues to operate care homes.
She also said she’d have liked to see a Regulation 28 issued, which is a report a coroner can order when they believe action should be taken to prevent further deaths.
Mrs Arden said that she and the families of Mr Lowlett and Mr Poole will consider any next steps when all three inquests are complete.