Care watchdog CQC 'unreservedly' apologises to George Lowlett's family during inquest into his death

A health regulator has apologised for failing to follow its own processes after the death of a former resident of The Elms Care Home in Whittlesey.

Hazel Roberts, deputy director of the Care Quality Commission (CQC) for the East of England, said she “unreservedly apologises” to the family of George Lowlett, who died in February 2019 after several months at the home.

An inquest into his death heard that an initial assessment of an incident at The Elms regarding Mr Lowlett’s care “wasn’t conducted by CQC inspectors as we would expect in line with our practices”.

The assessment, based on a complaint after Mr Lowlett’s death, could potentially have identified ongoing risks of harm to other people.

Having developed a chest infection while at the home, Mr Lowlett was taken to Peterborough City Hospital where he was diagnosed with sepsis – a life-threatening reaction to an infection – and died shortly after on 18 February.

The CQC rated The Elms Inadequate after an inspection in June last year, which was partly triggered by concerns raised by Mr Lowlett’s family.

The CQC’s 2022 inspection resulted in The Elms being shut down, while Cambridgeshire County Council (CCC) suspended admissions to all care homes operated by HC-One - the national provider which had operated it.

HC-One applies to have council embargo on its care homes lifted

The inquest heard from Leesa Murray, head of contracts at CCC, that the council took this decision because it was concerned by a “failure to sustain improvements” and that there is no current timeline for ending this embargo.

But the company has applied to have it lifted, the inquest heard, with CCC expected to respond shortly.

“In broad terms, we’ve seen improvements,” Ms Murray said of the remaining HC-One homes in Cambridgeshire, but sustaining these is the council’s biggest concern.

“There’s a pattern of improvements then those improvements not being sustained,” she said.

Two of HC-One’s three other Cambridgeshire homes are rated Requires Improvement, while the other is rated Inadequate, the inquest heard.

But the company’s senior area director Jonathan Richards said he’s “confident we’re in a very different place” from when those inspections took place and that there has been a change in team since.

George Lowlett's care not always 'safe and effective'

The inquest heard from expert witness Dr Jane Douglas that, in his final days at The Elms, the Mr Lowlett’s care was not always up to a “safe and effective” standard.

In the days leading up to his admittance to hospital, home care records are “difficult to follow”, Dr Douglas said, meaning it’s not possible to say, for instance, whether he was actually out of bed for 13 hours while unwell or whether his records just hadn’t been updated.

There may have also been missed signs of his deterioration, she said, while there were occasions in which his temperature, blood pressure and other vital signs were recorded as having been checked but the readings not written down.

The Elms staff 'did the best they could'

Record-keeping was also discussed with Elms staff.

Coleta Bartolome told the inquest it was possible that health care assistants at The Elms would have recorded that they had told nurses such as herself something about a resident which they hadn’t and that in fact this happened “quite frequently”.

But Elms manager Katie Coulson said she wasn’t aware of this happening.

“Nurses and the staff normally worked very well together,” she said.

She also described herself as a “very hands-on manager” and said her staff “all did the best they could”.

The inquest into Mr Lowlett’s death is scheduled to conclude on 30 March.

It was immediately preceded by an inquest into the death of Margaret Canham and will be followed by an inquest into the death of David Poole, two other former Elms residents who died within around a month of each other.

The inquest continues.