Suffolk coroner raises concerns after death of 81-year-man following 'neglect' at Stowmarket Chilton Meadows Care Home
Concerns over staff inexperience, training and assessment of care needs have been raised by a coroner following the death of an 81-year-old man.
Roland Stannard died in October 2020 following a stay at Chilton Meadows Care Home, in Stowmarket, which is operated by Bupa.
On August 12, an inquest concluded Mr Stannard died as a result of a serious infection caused by a sacral sore which developed as a direct result of his being left on a commode chair overnight, against a background of changes to his medication which reduced mobility and responsiveness.
Following the inquest, Suffolk coroner Nigel Parsley issued a report to prevent future deaths, which has been sent to Sajid David, the secretary of state for health and social care.
"Being left seated for a protracted overnight period, unsupervised and without the required basic care, amounts to neglect," said the report.
The medical cause of death was confirmed as sepsis, infected wounds from pressure sore and frailty/dementia.
Mr Stannard died at West Suffolk Hospital on October 3, 2020.
He was admitted on September 9 suffering from a serious pressure sore on his sacrum. It had developed over previous weeks, while he was resident at Chilton Meadows Care Home, in Union Street, having been admitted there on June 25.
Due to miscommunication and miscoordination between health care professionals and staff, a lower than usual dose of medication to treat Mr Stannard's vertigo migraines was administered from June 25 before being stopped completely on July 31.
On the evening of August 22 and overnight into August 23, Mr Stannard was left sitting on a commode chair for at least 13 hours, but possibly much longer – triggering the development of a sore – while his four to six hour incontinence care was not carried out.
"Due to staff inexperience and lack of training, equipment provided to reduce the further development of the sore was wither not utilised or, if utilised, sometimes used incorrectly.
"The above factors led to Mr Stannard receiving sub-optimal care, allowing his serious sacral sore to develop," added the report.
A high-grade air alternating mattress was set to the incorrect height for someone of Mr Stannard's weight, while an automatic lateral turning system was unplugged.
Mr Parsley said while some changes had been made at Chilton Meadows, he was concerned about training and staff knowledge in relation to the provision of specialist equipment to any care home setting.
Meanwhile, he has also questioned at what point assessment should be made to identify whether a patient needs nursing care rather than social care.
Linda Burrows, regional director for Chilton Meadows, said: "We are deeply sorry for the errors in Mr Stannard’s care and our thoughts are with his family.
"We have since made significant changes to prevent this happening again.
"These include further training for colleagues and increased staffing across the home.
"We’ve also appointed experienced unit managers to oversee changes who are having a positive impact across the home."