Thread by @GeorgeJulian

Spent day reading PFDs (Prevention of Future Death) reports and associated stuff. So disheartening to see same issues crop up repeatedly. Am gonna share one lowlight, whilst recognising these are only written due to ongoing concerns after someone has died..

so really they're all lowlights. In my experience NHS Trusts and care providers will do *anything* to avoid being issued a PFD, it's like reputation is all that matters.

I'd like to share about John Gregory, he was 93 when he died in October 2019 judiciary.uk/publications/j…

'Mr Gregory died because he had not been drinking enough, though his Alzheimer’s was not end stage, and before he was admitted to hospital he had been mobile; able to wash, dress and feed himself; and enjoy a good quality of life'

Mr Gregory had a short stay in hospital, followed by 7wks in a St Pancras Hospital rehabilitation ward, before discharge to a residential and nursing home run by @careuk, Muriel Street. His health deteriorated in the home and he was readmitted to hospital 3wks later.

[Where presumably he died. I say presumably because there was a narrative verdict that we've no access to on the PFD database. It's not the most helpful system].

So what happened to Mr Gregory? This is what we know...

It sounds fair to say his care on the #NHS rehabilitation ward wasn't exceptional, but there was an impressive sister in charge with high standards. Attempts were made to address his fluid intake, but records indicate it remained too low.

The impression we get is that not all staff upheld the sister's standards, and maybe more consistent efforts could have been made to get Mr Gregory to drink. We hear that his family had concerns about toileting.

It doesn't take a rocket scientist to question whether Mr Gregory was reluctant to drink, because he was left to sit in wet clothing. Anyhow, that's just my posturing. I guess we can assume Mr Gregory was fit for discharge from the rehabilitation ward to the @careuk home.

The Coroner raises a number of concerns in her PFD about the 'care' provided by @careuk:

1) 'On the day he was readmitted to hospital from Muriel Street, Mr Gregory’s family found him slumped unconscious in a public area of the home, a fact unnoticed by any member of staff'

[Can you imagine Mr Gregory's family going to visit and finding him in this state. Given the profits taken by @careuk I'm fairly sure that this provision wasn't cheap, and they couldn't even do the basics]

2) 'He was not properly strapped in to a wheelchair, slipping down because his feet were not on the foot rests. He was cold and inadequately dressed, with his shirt undone and not wearing socks. By then Mr Gregory was not capable of dressing himself'.

[This enrages me; before his stay in hospital Mr Gregory had a good quality of life, it's not hard to imagine that he was a well turned out gentleman, most 93 year olds I've known don't tend to wear unbuttoned shirts and no socks or footwear, unless they're at the beach]

[The very fact it was noteworthy to his family indicates it was out of character. Imagine turning up to find your loved one unconscious, cold, slumped half in, half out of a chair. In a 'care' home @careuk]

The Coroner continues:

'Mr Gregory’s oral fluid intake was also too low at Muriel Street, a nursing home specialising in the care of those with dementia'.

[Here we find out that this is specialist dementia care from @careuk]

'On his last day at the home, Mr Gregory was described in the nursing notes as drinking, but his chart showed that he had drunk nothing since a cup of tea at 8.20am. The ambulance was called at 5.17pm.'

[Specialist dementia care. No fluids in 9hrs despite a known risk]

'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'.

[Perhaps not a surprise given they'd not noticed he was unconscious in a public area of the home]

'His fluid intake chart recorded him as repeatedly declining drinks, even at a time after he had lost consciousness and an ambulance had already been called for him.

This demonstrates that the chart was inaccurate'.

'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'.

The Coroner raises these concerns and the standard reminder that 'In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action'.

@CareUK get 56 days to provide a response detailing how they'll address the concern

So, how do @CareUK respond I hear you asking.

Do they go full mea culpa, we'll do better in future, pinky promise?

Do they show exceptional compassion to Mr Gregory, his family and all those who loved him?

Do they demonstrate the desire to truly learn and protect others?

Spoiler alert: No, they don't. Their response is amongst *the* most arrogant and entitled, not to mention confrontational, that I've had the mispleasure to read.

You can read it in full here judiciary.uk/wp-content/upl…. I'll screengrab relevant sections.

They start with the bog standard, look we've made lots of changes since this death, but we 'welcome the opportunity to consider future improvements'

[Why do @CareUK need a Coroner to nudge them into considering future improvements?]

This is followed by such a pernickety point, it really got my back up. The wording, such entitlement and arrogance, correcting the Coroner on who she should have addressed her PFD to.

[I guess in @careUK's world it's all about them, not about Mr Gregory, or anyone else]

What do they have to say about Mr Gregory being slumped, half dressed in a wheelchair. Are they full of remorse?

Nope. @CareUK respond 'for completeness' by correcting the Coroner and saying this was not on the day Mr Gregory was returned to hospital, but on his arrival.

Wow, specialist dementia care from @careuk with a heavy dose of arrogant, entitled sniping.

A begrudging admission that he should have been moved to an armchair in his room [where he'd be out of sight and out of mind no doubt].

This is followed by paragraphs and paragraphs of waffle about manual handling - training plans, compliance reports, systems, policies and manuals

[None of which can explain away why Mr Gregory was left as he was]

Hidden deep amongst @CareUK waffle is an admission that 'the training has been improved... now includes a specific section on wheelchair safety guidance'

[Specialist care; people in wheelchairs must be as rare as hen's teeth, can't have foreseen the need to know that]

[As an aside @CareUK you don't need to say 'Mr Gregory's sad death', drop the sad. It's his death. Clearly an inconvenience to you, but don't bother with the fake sadness]

What else did they have to say for themselves?

Turns out they've apparently increased staffing, and now 'undertake specific welfare checks upon residents at regular intervals throughout the day'.

[I mean, help me out here, what the feck did they think specialist dementia care involved?]

Oh, and they record that apparently on 'welfare check sheets'

[Bit like they recorded fluid intake when Mr Gregory was there no doubt; which the Coroner raises concerns about because you have to question the accuracy of fiction]

The @CareUK response then moves on to 'Being found inadequately dressed shortly before his transfer to hospital'.

[What are the odds on a decent, compassionate, sensible response? Slim to none I'd say]

'@CareUK and Muriel Street take the safety, welfare and dignity of residents seriously. To this end, there are a number of systems, policies and guides which govern and guide staff in this respect'

[*shouts* this doesn't address why Mr Gregory was found half undressed]

This is followed by attachments of policy documents, how to guides, and ways of working documents

[None of which address why Mr Gregory was found half undressed... @CareUK seem to have a fundamental misunderstanding that paper and policies = care]

Then we hear about a clothing inventory, laundry arrangements, wardrobe checks and clothing labels.

'Since this incident, the requirement to ensure that resident's are appropriately dressed was specifically discussed'

[You couldn't make this response up, it's so bad]

Note also the throwaway pandemic mention [another reason why the carers = heroes stuff aint helpful, because some just aren't, despite companies making huge profits off the back of poorly paid over stretched staff]

What do they have to say about Mr Gregory 'Being found in an unconscious state without any apparent staff support or monitoring'.

'The welfare and safety of residents in the foremost priority of @CareUK and Muriel Street'.

[Their typo and so tone deaf with it]

[None of their answers really address the heading they claim to address]

We hear again about documentation, welfare checks, handover meetings, audits

[Surely all of this stuff was happening anyway @CareUK]

More training. More promises.

'Additionally, since Mr Gregory's death, all nursing staff have undertaken a clinical skills workshop, part of which deals with the identification of the deteriorating patient and monitoring of the same, details of which are attached'.

[Surely any nurses working in specialist dementia care that can't spot a 'deteriorating patient' shouldn't be working there in the first place. This is a whole level of exceptional waffle].

Finally 'Monitoring a resident's oral fluid intake' you can all guess the first line...

'@CareUK and Muriel Street recognises the importance of ensuring that a resident's hydration is carefully monitored'.

[Except there's clearly a gulf between the words and the practice, because this PFD is issued because you failed to do precisely that, in practice]

[This is making my head and heart ache]

'Since the death, Muriel Street has started and continues to educate staff of the need to encourage residents with oral intake of fluids'.

[The death. Such entitlement, arrogance and disregard from @CareUK]

Does anyone check whether specialist dementia care providers actually provide specialist care? @CareQualityComm @DHSCgovuk @MattHancock Anyone.

It takes a death for 'specialist providers' to learn to educate their staff to encourage residents to drink?

I'm done. I was going to tweet about an impressive PFD I found. Well an impressively detailed Coroner's working outs, but I'll save that for another time. I need to go and bang my head off the nearest wall.