Care Home’s ‘Neglect’ Contributed to Sepsis Death of Resident – Coroner

Published on: 20 Sep, 2023
Updated on: 22 Sep, 2023

Entrance to Hydon Hill Care Home Wikimedia

By Emily Coady-Stemp

A Surrey care home’s “neglect” contributed to the death of a resident, according to a coroner.

In the final days of her life, the care home did not tell the resident’s GP about a positive urine sample, did not start her on antibiotics, and did not pass on key information to paramedics.

The 61-year-old, who we are choosing not to name, died after a urinary tract infection spread to her kidneys and caused sepsis.

She had been living at Hydon Hill Nursing Home, Hydestile, near Godalming, which is run by Leonard Cheshire.

Her death at the home on January 3, 2022 was subject to an inquest which finished on July 3, with Anna Crawford, assistant coroner for Surrey publishing a prevention of future deaths report in August.

Miss Crawford found her death was “contributed to by neglect on the part of Hydon Hill Nursing Home”.

A Leonard Cheshire spokesperson said they had received the coroner’s report and were looking at the conclusions in it.

They said: “We take the responsibilities we have for people’s care extremely seriously.

“The death of anyone in our services affects us deeply. Our thoughts remain with everyone who knew [her].”

The coroner said policies and procedures should be updated regarding sharing and documenting information relating to residents as well as in relation to training of clinical staff to address the issues.

As a result of severe progressive multiple sclerosis, the woman was bedbound and had minimal communication abilities, according to the report.

After a visit from her GP on December 31, 2021, she was prescribed stand-by antibiotics to be given if her condition deteriorated, with instructions to admit her to hospital if she began to show signs of sepsis.

Her GP thought, given her history, that she may be in the early stages of urinary sepsis, and asked for a urine sample to be taken and delivered to the surgery for testing.

But staff at the nursing home did not tell the GP about a positive urine test from the previous day, nor was the doctor made aware of the second positive test carried out by staff at the surgery.

Miss Crawford’s report said: “In the event that that [her] GP had been informed of either of the positive dipstick test results, [she] would have been immediately commenced on oral antibiotics and her life would have been prolonged, albeit it is not known what her ultimate prognosis would have been.”

She also said that had antibiotics been started on the evening of December 31, when the 61-year-old’s consciousness levels deteriorated, her life “would have been prolonged”.

Staff also did not inform paramedics, who were called the day before she died when her blood pressure deteriorated, about a positive urine test or about the plan to admit her to hospital with any signs of sepsis.

This information also would have prolonged her life, though still without knowing what her ultimate prognosis would have been, according to the report.

On this occasion, she was not transferred to hospital and was discharged back to the care of her GP.

Miss Crawford also said that there were errors in the home’s response when nurses found her to be “pale and unresponsive” and called 999 on the day she died.

Life support measures were not put in place after the call for an ambulance, because a nurse at the home said the resident was “breathing very slowly and had a weak pulse”.

But on arrival, paramedics found her to be in a state of cardiac arrest and were incorrectly told by nursing home staff that she had a valid Do Not Attempt to Resuscitate (DNAR) form in place.

The coroner had found that in fact there was no valid DNAR in place and that her express wish was to be resuscitated in the event of a cardiac arrest.

Miss Crawford said: “It is of considerable concern that the trained nurses at the care home were unable to recognise that [she] was in a state of cardiac arrest.

“It is also a matter of considerable concern that staff did not know what [her] wishes were in the event of a cardiac arrest and therefore did not commence life support measures on 3 January 2022.”

But during the inquest, the court was not persuaded that the absence of life support measures contributed to her death.

The Leonard Cheshire spokesperson said the organisation would respond to the coroner’s report by the deadline given, after a further review both nationally and at the home of the circumstances and the measures taken.

They added: “Any further lessons to be learned from this tragic case at Hydon Hill, following our actions to date, will be.

“Further training was undertaken by nursing staff with an internal audit of the service and competencies also undertaken.

“New processes have been implemented, including around clinical governance, to identify areas of concern early.

“We are currently reviewing all policies and procedures as part of our ongoing commitment to care quality.”