“5 (1) To Westmorland Court”

The coroner’s concerns

– 5 (1) To Westmorland Court. The General Practitioner who came to give evidence said that care had improved since Reg's death but he still had concerns about care given and had to visit regularly every week to check residents -the only one of six homes he covers that requires this level of support. He said it was a struggle to provide good quality care and felt this report would be helpful -as I stated at inquest it is not intended in any way to be punitive but to put focus on areas that may be improved. A particular concern was clear evidence that examinations entered into Reg's notes were made at times when this was impossible because he was in hospital -this puts into question the reliability of notes generally. (2) To Care Quality Commission. You requested a note of the outcome of this case and please accept this report as such. I imagine you will be making further enquiries. There was no defibrillator in the home at the time of this incident although I am told one has now been installed. I was told that it is not a requirement for care homes to have one. If staff in these homes are expected to attempt resuscitation should provision be required? (3) To Nursing and Midwifery Council. A Registered nurse was in charge of the home on the night of Reg's injury. Her statement told us that she forgot her basic training and had never had to attempt CPR before. Despite clear signs of breathing and resistance to her efforts she continued to be guided by the call handler at NWAS who had been confused by her inconsistent responses to his questions. Basic checks and signs of life were ignored. I was told at inquest that after being stepped down from nursing duty for a while she had had further training and was back in position. I was told that a referral to yourselves had been made and acknowledged but nothing further had been heard, has the referral been closed?

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, 2024-0429

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