HC-One inquests: Families of former Whittlesey Care Home residents don't want others to 'suffer the way that we have'

The widow of a former resident of The Elms Care Home in Whittlesey has said she wants to “bring about change, raise awareness and make improvements to the benefit of the wider community” in the wake of her husband’s death.

Jeanne Poole was among the bereaved family members who attended an inquest into the deaths of three former Elms residents who died within around a month of each other in early 2019 held this week.

Mrs Poole asked questions at the inquest on behalf of her late husband, David Poole, while Kim Arden represented her grandmother Margaret Canham and Laura Newell represented her father George Lowlett.

The women asked questions of The Elm’s former manager and nurses, as well as its operator HC-One, local authority Cambridgeshire County Council (CCC) and the Care Quality Commission (CQC).

The “landscape of care in Cambridgeshire is now changed” because of their years-long advocacy for their family members, coroner Caroline Jones said.

The Elms shut down last year following an CQC inspection partly triggered by the families' complaints, while CCC suspended admissions to all HC-One homes.

Speaking after the conclusion of the three inquests, Mrs Poole said that she doesn’t want “other families don’t suffer the way that we have”.

“After four years, I am satisfied that the circumstances leading to David’s death have been thoroughly reviewed by the coroner,” she continued.

“This process, together with the inquests of Margaret and George, has brought focus to the provision of care to the vulnerable elderly and wider community. I hope our efforts will be of benefit.”

Mrs Newell, meanwhile, said that she’s “glad we got the hybrid conclusion which brought in the faults of the care home”.

In the cases of Mr Lowlett and Mrs Canham, Ms Jones returned a short conclusion of natural causes supplemented by a short summary of the circumstances surrounding their deaths, or a hybrid conclusion.

Both died in Peterborough City Hospital within days of each other, having contracted a chest infection at The Elms before developing sepsis – a life-threatening reaction to an infection.

Mr Poole’s outcome was simply a short conclusion of natural causes because he survived his hospital stay after leaving The Elms, although he died just over a month later while receiving palliative care at another care home.

In all three cases, problems with their care at The Elms were identified, although not ruled to be causative factors in their deaths.

These included inaccuracies with record-keeping, delays in spotting early warning signs of oncoming illness and failure to always administer prescribed medication.

Mrs Arden said that the hybrid conclusion in relation to her grandmother’s death was a “pleasant surprise” and that Ms Jones had “taken a lot on board of what we’ve been saying”.

But while the inquests into the deaths of Mrs Canham, Mr Lowlett and Mr Poole have concluded, Ms Jones must now decide whether or not to issue HC-One with a Regulation 28 report, prepared when a coroner believes measures should be taken to prevent future deaths.

Ms Jones has given all parties until 21 April to submit any more documents before she makes her ruling.

HC-One sends families sincere apologies

A HC-One spokesperson apologsided to the families.

“We are clear that The Elms should have provided far better care to Mrs Canham, Mr Lowlett, and Mr Poole,” they said.

“We sincerely apologise to the three families involved for our shortcomings, for their experience engaging with our teams, and for the upset that has been caused. We hope this week’s outcomes provide some sense of closure for them.

“The management team in place at The Elms at the time, and the regional management team responsible for overseeing the home, fell far short of everyone’s expectations and standards, and did not live up to our values of transparency and accountability. These individuals are no longer employed by HC-One.

“Our mistakes were acknowledged early on, which is why compensation payments were previously offered to all three families. A full, independent, and public account of the care provided to Mrs Canham, Mr Lowlett, and Mr Poole was always going to take place at these Inquests, irrespective of whether the families accepted a compensation payment or not.

“Record keeping has been a major theme in these Inquests. The system we use across all our homes has – when used correctly – been proven to achieve the highest Care Quality Commission grades. However, The Elms did not use this system correctly which led to unacceptable mistakes in the care of Mrs Canham, Mr Lowlett, and Mr Poole. To prevent similar mistakes from happening again we have improved the staff training across our organisation, and we are currently in the process of moving to a fully digital care record system. This will bring improvements to ease of accessing information and enable greater oversight from our central support centre.

“A lot has changed in the organisation over the past four years, but we know we still have a lot more to do to win back the trust of people in Cambridgeshire. We have new management in place, and dedicated regional support, who are working hard to make specific and targeted improvements to our homes within the county. The feedback we have been receiving demonstrates we are moving in the right direction.

“We will review the Coroner’s rulings and recommendations from all three cases in detail and will make any requested changes as quickly as possible. Our priority is that every Resident living in one of our homes receives the very best care and we are constantly working towards this.”