Whittlesey home resident died from natural causes but received 'suboptimal level of care', coroner rules

A former 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.

‘Suboptimal level of care’

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.

Family 'let down' by home, council and regulators

Speaking before the inquest’s conclusion, Mrs Canham’s granddaughter Kim Arden said that she doesn’t believe better handling of records and care is being implemented across HC-One.

“My nan was failed and if something’s not done there’ll be other lives lost,” she said.

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 HC-One’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.

'Lack of attention to care and support' at The Elms

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 continued that it’s not possible for her to say whether Mrs Canham’s outcome would have been any 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.

Care 'not safe and effective'

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.

The conclusion of Mrs Canham’s inquest will immediately be followed by inquests into the deaths of George Lowlett and David Poole, both former residents of The Elms who died within around a month of Mrs Canham.

The consecutive inquests are expected to last until 31 March.