HC-One: 'Landscape for Cambridgeshire care now changed' after three families’ fight for justice - coroner

The “landscape for care in Cambridgeshire is now changed” after three families’ tireless fight for justice, a coroner has said.

Caroline Jones ended the last of three back-to-back inquests into the deaths of former residents of The Elms Care Home in Whittlesey with a tribute to the families who have spent years preparing for the proceedings.

Between their deaths - all within around a month of each other in early 2019 - and the conclusion of the inquests, The Elms was rated as Inadequate by the Care Quality Commission (CQC) and shut down.

Cambridgeshire County Council (CCC) also suspended admissions to all care homes run by its operator HC-One, although a decision on whether or not to keep this embargo in place will be communicated to the company next week.

The final inquest, heard on March 31, is related to David Poole, who died aged 74 at the Ashlynn Grange Care Home in Peterborough on 24 March, 2019.

Ms Jones ruled that he died of natural causes, namely dementia contributed to by Parkinson’s disease.

Just over a month before his death, Mr Poole suffered from a chest infection at The Elms before being taken to Peterborough City Hospital where he was diagnosed with sepsis.

But he recovered enough to be discharged, and was moved to Ashlynn Grange Care Home in Peterborough where he died after receiving palliative care.

Care at The Elms 'not safe and effective'

At The Elms, Mr Poole’s care was not “safe and effective” in his final days at the home, Ms Jones ruled.

There were inaccuracies and omissions in his medical records and his medicine wasn’t always administered properly.

It’s not clear that his complex medical needs were properly understood, she continued, and this may have “prolongued and exacerbated” his discomfort.

But while suffering from sepsis can’t have improved his strength, it could not be considered causative of his death because of intervening events, she said.

Ms Jones deviated slightly from her two earlier rulings, recording a short-form ruling of “natural causes”.

In the cases of Margaret Canham (97) and George Lowlett (90), she recorded a slightly longer ruling, to reflect the circumstances around their deaths which were both due to sepsis shortly after leaving The Elms.

Former resident was 'young at heart, with a zest for life'

Mr Poole was a “fearless” and “adventurous” man who was “young at heart, with a zest for life,” his widow said.

He was a communications engineer in his younger years, before the onset of his illnesses.

Ms Canham was represented at the proceedings by her granddaughter Kim Arden, while Mr Lowlett was represented by his daughter Laura Newell.

Despite the three inquests concluding, the proceedings aren’t over yet.

Ms Jones must also 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.

A decision is expected on 31 March.