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Cllr Catherine West |
Probe into ‘panic’ at care home
Niece demands answers over 999 delay as uncle lay dying
CRITICISM by a coroner of a private care home after the death of a patient has sparked calls for an investigation.
Islington’s opposition Labour leader Councillor Catherine West asked for spot checks of all private care homes across the borough and an official inquiry into the death of retired electrician John Jackson.
Her request came after it took staff at the Cheverton Lodge Care Home, in Upper Holloway, almost 20 minutes to call for help for Mr Jackson – and even then there was confusion over whether they called for the police rather than an ambulance, an inquest heard on Monday.
Coroner Dr Andrew Reid told St Pancras Coroner’s Court that he planned to write to Islington Primary Care Trust (PCT) over the lack of emergency procedures in place at the home.
He also said he would recommend all nurses across Islington’s care homes be retrained in heart massage – known as CPR – to give patients “a chance” of survival.
This is what happened when Mr Jackson had a heart attack at the 52-bed care home four months ago:
• At 12.15am Mr Jackson collapsed in the bed while a nurse is present.
• The nurse applied chest compression, part of the standard CPR heart massage procedure.
• Mouth-to-mouth was not given to Mr Jackson, despite this being part of accepted CPR treatment.
• At 12.40 the police were called, but on arriving at the care home, they failed to be given any real information.
• At 12.45, paramedics arrived and pronounced Mr Jackson dead.
Divorced Mr Jackson had only been at the home a week when he died.
It emerged during the inquest that Mr Jackson failed to receive effective CPR for up to 30 minutes.
Staff also admitted Mr Jackson was dying for 20 minutes before they called for help – and even then, the task fell to the same nurse administering CPR.
Prior to Mr Jackson’s admission to Cheverton Lodge, he had been a patient at the Whittington Hospital in Archway after suffering kidney problems and a range of associated illnesses.
His discharge from hospital was “poorly planned” according to notes from his GP, which were read out by the coroner.
He was admitted to Cheverton Lodge under a deal between the borough’s PCT and the care home to admit patients in need of medical care. The manager of Cheverton, Mary Rabbitte, said the home had agreed “a few years ago” to take in patients “who are discharged unsuccessfully”.
Cheverton Lodge is run by Barchester Healthcare, which is one of the country’s most financially successful providers, pitching at the grey pound with its string of upmarket care homes.
The company regularly posts profits of tens of millions of pounds and has been financially supported by the racing tycoon John Magnier.
At several times during the inquest Mr Jackson’s niece, Christine Goodwin, quizzed witnesses from the care home about whether her uncle had been given his oxygen – prescribed to treat his kidney condition.
Grilling the home’s manager, Ms Goodwin questioned why staff had panicked when her uncle went into arrest.
She said: “I can understand it must be quite a shock but I would hope, as a trained professional, they would take over and not panic. There didn’t seem to be a set of procedures. There should have been one [nurse] doing CPR and another making the phone call [to the emergency services].”
Ms Rabbitte replied: “I can appreciate your concern, but we don’t normally see sudden death – it is traumatic.”
Ms Goodwin retorted: “She should be dealing with things she’s trained for, rather than call for medical help.”
“I appreciate your concern,” repeated Ms Rabbitte.
Ms Rabbitte went on to say her staff were all compliant with regulator CSCI, and said they were due for a refresher course in January.
“A sudden death is really traumatic,” she said. “We don’t come across them often. I can appreciate what Nurse Paz [Ballesteros] went through. Skills-wise, we can only take that forward in January. As human beings, we panic.”
Dr Reid acknowledged during her evidence that, even in hospitals, most people who suffer heart attacks die.
Ms Rabbitte refused to comment to the Tribune afterwards.
Nurse Ballesteros gave a confused account of the night Mr Jackson died. She said: “I panicked. It was first time to experience sudden death but I did my best for him.”
She also couldn’t recall how long she did CPR for, or how long it took to call the emergency services.
When asked why Mr Jackson wasn’t moved to the floor to receive CPR, she failed to give a clear answer.
In broken English she said: “Yeah but... because we’re supposed to but we knew Mr Jackson... there was no response there... we tried to put him in firm mattress but we didn’t have time because of panic really.”
Paramedics and police who gave evidence both described feeling unhappy with the situation that faced them when they arrived.
PC Michael Hesp of Islington police said nurse Ballesteros appeared “nervous”, while DS Keith Paterson said “it was almost like charades” trying to work out what had happened. Paramedic Joseph Philips also complained staff were not direct with information.
Dr Reid recorded that Mr Jackson died of natural causes, but ruled he could not reach a conclusion on whether neglect had contributed to his death.
He said: “It is difficult to establish whether levels of skill contributed to his death, but on the evidence the level of skill was not grossly lacking – he was receiving attention but it did not comply with recognised guidelines.”
He described the care Mr Jackson received the night he died as “not adequate, sufficient or effective”.
He added: “This case raises concerns about the skills of staff nursing patients at the Cheverton Lodge.
“I accept evidence from the manager that there should be some attention to training of staff. Basic life support is something which nurses should be confidently skilled in.
“I intend to write to the PCT. The issue of training and education should be reconsidered for all the nursing homes within its jurisdiction.”
Cllr West said details of the inquest were of grave concern. “Procedures at the home need to be looked at,” she added. “We need spot checks to make sure these establishments are being run well.
“Our security committee needs to carry out a proper inquiry into the circumstances to see if lessons can be learned.”
Islington PCT said regulation of care homes was in the hands of CSCI, and the coroner should direct his letter to them.
A Cheverton Lodge spokeswoman said: “We respect the privacy of our residents and staff in all matters and are therefore unable to give any further comment.” |
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