Whittlesey care resident subject to 'catalogue of failings' before her death, inquest hears

An inquest into the deaths of three former residents of The Elms Care Home in Whittlesey began at Peterborough Town Hall on 27 March.

Margaret Canham (97), George Lowlett (90) and David Poole (74) all died within around a month of each other in early 2019 after living at the home.

The Elms was shut down last year after being rated Inadequate by the Care Quality Commission (CQC).

It had been operated by HC-One, one of the biggest care home providers in the UK, which continues to operate nearly 300 homes.

Shortly before The Elm’s closure, Cambridgeshire County Council (CCC) suspended admissions not just to The Elms but to all care homes operated by HC-One in the region.

Representatives of The Elms, the CQC and CCC all gave evidence at the inquest, but not before coroner Caroline Jones heard from Mrs Canham’s granddaughter, Kim Arden.

Relative felt 'lied to and misled' by home

Mrs Arden said at the hearing that she felt lied to and misled by HC-One, which she also said offered her money.

She said that her Mrs Canham was “subjected to a catalogue of failings” for which she'll "never forgive" the company and that her grandmother's final days have left an “imprint on my heart which will never heal”.

At the time of her death, Mrs Arden was already looking into alternative care homes for her grandmother, she said, and had raised concerns about her care.

In her witness statement, she recounted an incident in which her grandmothers’ records at The Elms stated that a head injury she had endured was as the result of a TV remote control hitting her either because it became tangled in her bed or surrounding wires, but reports to GPs blamed it on a fall.

Mrs Arden also said that staffing levels at The Elms were so low that families were given keypad codes to get in and out.

On the day Mrs Canham was admitted to hospital, Mrs Arden said that she went to see home manger Katie Coulson on site but was told she would have to wait until she had finished a call.

Ms Coulson, who also gave evidence to the inquest, said that she immediately left her call to attend to Mrs Arden.

The purpose of an inquest is not to apportion blame, but to establish how and why a death has occurred.

The circumstances around a death may also be discussed.

Ms Canham died at Peterborough City Hospital where she had been treated for Sepsis just over a week after she left The Elms.

The Elms didn't have full staffing occupancy

Giving her evidence, Mrs Coulson confirmed that on some of the dates during which Mrs Canham became ill that the home didn’t have full staffing occupancy, but said that it was still operating safely as there were 29 residents there at the time rather than the full 37.

Ms Arden, who was allowed to ask each witness questions, told Ms Coulson that she “can’t see anything” on a care home report on her grandmother’s illness and admission to hospital that was correct.

Mrs Arden said that the times her grandmother was seen, the time the family were informed of her illness and the date the incident began were all incorrect.

The coroner, meanwhile, noted that it might be “confusing” that information about residents and their health was routinely recorded in four different places at The Elms.

Relative will 'never be free of the sight' of her grandmother's condition

Another point of contention occurred over Mrs Canham’s condition on the morning of 14 February.

Mrs Arden said she will “never be free of the sight” of her grandmother sitting bound in a blanket in her chair with her breakfast untouched.

She took a photo of this, which she says was taken at 10:01am.

But carer David Redford, one of several care and medical staff involved with Mrs Canham in her final days at the home, said that when he left her room that morning she had started to eat her breakfast.

Mr Redford was also the member of staff who took some initial tests and concluded that Mrs Canham should see a GP.

She saw a nurse later that morning who called the ambulance which took her to hospital with suspected pneumonia.

According to a witness statement from The Elm’s Clinical Service Manager Rachel Jolly, Mrs Canham tested negative for infection in 11 February – three days earlier – but on 12-13 February had symptoms that meant she required first observation and later the attention of a GP.

CQC apologises for pace of inspections

The first day of the inquest concluded with evidence from the CQC and CCC.

The CQC’s deputy director of operations for the East of England Hazel Roberts confirmed that The Elms was inspected in August 2019 after concerns were raised over Mrs Canham’s case and others.

It was rated Requires Improvement.

A second full inspection in October 2021 meant that this was downgraded to the lowest rating; Inadequate.

Between these dates Ms Arden contacted the CQC nine times providing documents and raising concerns.

Ms Roberts said that inspectors “should have gone in much sooner” and that she can “only apologise they didn’t".

In the same period, Mrs Arden sent complaints to CCC which upheld some of these on the basis that more monitoring work needed to be done.

Council has concerns about other HC-One homes

Head of service and contracted provision at CCC Leesa Murray said that “aggregate concerns led us to escalate and suspend admissions to all HC-One homes from July 2022”.

Asked why the council didn’t visit The Elms sooner, Ms Murray said that the council would allow professionals such as the CQC to carry out safeguarding checks first.

Donna Glover, assistant director for adult social care at CCC and Peterborough City Council (PCC), said she doesn’t believe there was anything the council could have done in the lead up to Ms Canham’s death that would have changed the outcome.

These CCC representatives, as well as Ms Roberts and Ms Coulson, are expected to give further evidence later this week.

Ms Canham’s inquest is the first of the three being held back-to-back and will conclude on 28 March.

Evidence regarding the deaths of Mr Lowlett and Mr Poole will follow.

The inquest continues.