Care home criticised over death of 93-year-old who ‘declined drinks’
Coroner reviews case of man who died of acute kidney injury and complications due to not drinking enough
29 May, 2020 — By Sam Ferguson
Coroner Mary Hassell: ‘It raises the possibility that when Mr Gregory was described as declining drinks, in fact staff were not taking any steps to encourage him to drink, or to eat’
A CORONER has questioned why staff at an Islington care home did not do more to encourage a 93-year-old man to take liquids shortly before his death, partly caused by not drinking enough.
Concerns have also been raised over the quality of nursing notes at Care UK’s Muriel Street Resource Centre, which recorded John Francis Gregory as declining drinks despite him being unconscious at the time.
Mr Gregory died at UCLH in October and his inquest found the cause of death as acute kidney injury and complications due to not drinking enough.
Hypertension, Alzheimer’s and old age were also noted by St Pancras coroner Mary Hassell, although Mr Gregory was described as “mobile” before being admitted to hospital, and was able to wash dress and feed himself and enjoy a good quality of life.
A prevention of future deaths report written by Ms Hassell raised concerns over the treatment received by Mr Gregory after his seven-week stint at UCLH and during the three weeks he spent at the care home.
Ms Hassell’s report said there was a “lack of escalation” at the Barnsbury care home around Mr Gregory’s refusal to drink.
She noted that Mr Gregory’s fluid intake chart recorded him as “repeatedly declining drinks” at a time after he had lost consciousness and an ambulance had already been called for him.
“This demonstrates that the chart was inaccurate,” said Ms Hassell.
“It raises the possibility that the chart was inaccurate in other ways. It raises the possibility that when Mr Gregory was described as declining drinks, in fact staff were not taking any steps to encourage him to drink, or to eat.”
On his last day at the home, the nursing notes described Mr Gregory as drinking, but his chart showed that he had drunk nothing but a cup of tea since 8.20am.
“The ambulance was called at 5.17pm,” said Ms Hassell.
“The fact that he had not drunk the whole day was not escalated to a senior member of staff and there was no evidence that any steps had been taken to deal with this.”
The report also describes Mr Gregory’s last day at the home, when his family found him “slumped unconscious in a public area of the home.”
His condition had gone unnoticed by any member of staff.
“He was not properly strapped in to a wheelchair, slipping down because his feet were not on the foot rests,” read the report.
“He was cold and inadequately dressed, with his shirt undone and not wearing socks. By then Mr Gregory was not capable of dressing himself.”
Ms Hassell’s report also said Mr Gregory may not have had enough encouragement to drink and eat during his time at UCHL, and added that the highest standards were “not always maintained by every member of staff”.
“On one occasion, a member of staff refused Mr Gregory’s family assistance to take him to the toilet; on more than one occasion his family found him in wet bedclothes; and he was put to bed at 7.30pm to fit in with nursing routine,” wrote Ms Hassell.
Care UK’s Regional Director Deliana Katsiaounis said: “We would like to again offer our condolences to the family of Mr Gregory. We accept that the care we provided to Mr Gregory on that day fell short of our usual high standards.
“We have already undertaken training with team members on keeping care plan records up to date, escalating concerns about a resident and the importance of hydration for all residents.
Ms Katsiaounis added: “We are confident the measures we have already reported to the coroner represent significant progress, but we remain focused on an action plan that will drive continual improvements to care quality.”
A UCLH spokesperson said: “Our sincere condolences go to Mr Gregory’s family and loved ones. We are very sorry for their loss. Evergreen Ward at St Pancras closed in March 2020 as part of a planned service reconfiguration exercise.
“While there was barely any criticism of the care Mr Gregory received at UCLH in the coroner’s narrative verdict, we have taken on board the comments made in the Prevention of Future Deaths report.”