An elderly care resident’s death has been blamed on an absence of qualified nursing staff when she lapsed into a medical emergency.
Essex Coroner Michelle Brown has written to the company which ran the care home where Maria Howell was living when she died on the September 28, 2019, from peritonitis at Basildon University Trust Hospital.
Her RIG tube – a narrow tube that is inserted into the stomach to allow liquid feed, fluids or medication – had fallen out the day before but could not be reinserted by the nurse on duty at Cranham Court nursing home in Upminster and Ms Howell was not taken to hospital until “some hours later”.
It was some hours later still that she had the tube reinserted at Basildon Hospital and was discharged back to her nursing home.
The same nurse was on shift when that evening around 7pm Mrs Howells became unwell.
No ambulance was called by the nurse until the day nurse came on duty, some 12 hours later.
Mrs Howell was taken by ambulance where it was diagnosed that she had peritonitis and died on September 28.
Ms Brown said in a report to prevent future deaths : “There is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you.
“The matter of concern are as follows – that the care home had a resident with specific complex needs, and they had no qualified nursing staff to reinsert a RIG tube which is time critical.
“That they employ staff whose clinical judgement on someone who is critically ill does not necessitate urgent medical attention.
A spokesperson for Holmes Care Group, which ran Cranham Court before its closure last year, said: ” Mrs. Howell was a much loved resident of Cranham Court nursing home, and her passing in 2019 remains a matter of deep regret for everyone who worked in the home. Our thoughts remain with her loved ones during this challenging time.
”We accept the findings of the coroner and are considering our response, including having already begun the process of updating and enhancing staff training for our care teams across the UK to minimise the risk of a situation like this arising again.
“Cranham Court nursing home closed in 2021, and the staff member in question was an agency worker who is no longer working in any of our care homes.”