Care home was ‘short-staffed’ as resident died

An inquest into William O’Connell’s death held at Harrogate Magistrates’ Court on Tuesday heard that Alexander Court was down two staff on July 6 last year when Mr O’Connell died.

Paramedics told the inquest that Mr O’Connell’s final moments were ‘undignified’ with people stepping over his body as food continued to be served in the dining room which was busy with elderly residents.

Paramedic Gordon Pollard said they moved his body into a side room shortly after he died as people were still walking past. “It was quite distressing and not very dignified.”

Recording a narrative verdict Coroner Rob Turnbull said: “It’s clear nothing could have been done to prevent Mr O’Connell’s death.

He said that 76-year-old Mr O’Connell, known as Willie to his friends and family, was being fed by a qualified nurse on the afternoon of July 6 2014.

He started to shake and dribble, however staff said this was normal as he suffered from Parkinson’s disease, and he was given a few minutes before finishing his meal.

Shortly after he had finished another member of staff noticed he was slumped in the chair and called for help.

Despite receiving CPR from members of staff and from paramedics, Mr O’Connell died. Mr Turnbull concluded: “He died of respiratory obstruction caused by unchewed pieces of food in his windpipe.”

Pathologist Dr Carl Gray told the inquest he found large pieces of food, including entire chips, in Mr O’Connell’s throat and wind pipe.

He said that the amount of food was the worst he had seen in his three decades working as pathologist. “It was remarkable the amount of food present.”

Mr O’Connell’s step-daughter Ann Marie Gregory told the inquest she felt her father’s death was ‘an accident waiting to happen and one that could have been avoided.’

She said: “It could have been avoided by very simple measures by making sure there was enough staff on the Tour De France days.

“That was something that could have been corrected very easily. We all had advance warning of the Tour de France coming up, we all know Christmas comes in December, we make plans for it.

Mr Turnbull said: “It’s clear nothing could have been done to prevent Mr O’Connell’s death.”

Speaking outside Harrogate Magistrates court Ms Gregory, a barrister, said she was ‘extremely disappointed’ with the Coroner’s verdict.

On Tuesday (April 28) the inquest heard from nurses and carers from Alexander Court, which charged between £550 and £725 per week for care before it closed its doors.

Nurse Mirela Tibuleac told the inquest it was her first shift as a qualified nurse when Mr O’Connell died.

She said: “It was the Tour de France so we had some problem with staff so we had to supervise all the people in one room.

“We couldn’t supervise the residents properly and do the rest of the tasks. We tried to call for other staff but none came because how would we transport the staff?”

Care Quality Commision (CQC) inspector Pam Cox said that in May 2014 they issued a ‘specific reminder to be mindful’ that the Tour De France weekend was approaching and that the care home should consider staffing

levels.

“We issued a notice to all the services in North Yorkshire about the disruption it was going to cause, there was a tremendous amount of work from other care homes and care agencies which they had to undertake to make sure the services were kept as they needed to be.”

Mr O’Connell’s death came among a series of CQC visits at the Care Home, following a number of problems identified in an inspection in March.

The CQC found a catalogue of errors at the care home which was formerly known as Waldernheath and notices for improvements were put in place.

Mr Turnbull said: “It seems to be the concerns were raised some time before the death.

“The death of Mr O’Connell, tragic though it was, wouldn’t have altered the CQCs regime at all.”

During a further CQC visit on July 15 Mrs Cox told the inquest that, she observed a man left alone, struggling to eat and choking. “He was unsupervised and he was eating chips with his hands, the food wasn’t going down and he was coughing.”

Elderly residents receiving nursing care were moved out of the home that month and the care home announced its intention to close its doors in completely in September.

After the inquest North Yorkshire County Council said: “We will now look closely at the issues that have been raised and will examine the matter with all interested parties, including Mr O’Connell’s family, if they wish.”

Debbie Westhead CQC deputy chief inspector for adult social care in the North, said: “We are currently working with all other agencies involved to review our actions in relation to Alexander Court to identify any lessons that can be learnt and we will build any findings into our new way of inspecting.”