“failure of the nursing home staff to recognise an acutely unwell resident; (2) failure of…”

The coroner’s concerns

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— (1) failure of the nursing home staff to recognise an acutely unwell resident; (2) failure of the nursing home staff to undertake appropriate action when they were aware of the low blood pressure; (3) a lack of ongoing training with regard to the recognition and treatment of acutely unwell residents; with reliance solely on initial nursing training; (4) failure of the nursing home managers to undertake an effective investigation into this incident and to take action to prevent repetition: (5) inaccurate reporting by the nursing home managers to the Care Quality Commission (CQC) that internal protocols had been appropriately followed, when evidence given at the inquest was that this was not the case; (6) lack of clarity as to the investigation that is to be undertaken by the CQC. The nursing home gave evidence that the investigation is closed, whilst the family believe it is ongoing; (7) the nurse primarily involved in this incident is no longer an employee at St Mary's and is working elsewhere. St Mary’s nursing home is therefore unable to take action to address potential future risks relating to the training of this nurse; (8) the potential for further incidents of confusion between driver and paramedic with regard to hospital transfer times, with the possibility of significant adverse consequences. Evidence given was that satellite navigation information (including time to arrival) was only available directly to the ambulance driver. Direct visualisation of a satellite navigation console by the non-driving paramedic could address this risk.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2014-0127

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0