Coroner says not enough evidence to rule care home death was preventable, reports Victoria Munro, Local Democracy Reporter
The grieving son of an elderly woman who died of pneumonia after being found in “concerning circumstances” at a Leytonstone care home has called for “major reform”.
Daisy Wood died of pneumonia aged 84 on 21st February 2019, after being rushed to hospital from St Catherine Care Home in Cann Hall Road, Leytonstone.
East London coroner Nadia Persaud found that staff’s failure to “adequately observe” Daisy meant she was unresponsive by the time a doctor was called to see her.
Daisy was prescribed the anti-anxiety medication Lorazepam earlier that month, after a physical assault by a member of staff at the care home had caused her psychological distress.
The coroner stated care home staff should not have continued to give her the sedative medication in the days leading up to her death, when she appeared drowsier than normal.
Her son told Walthamstow Coroner’s Court: “There’s been Lorazepam [wrongly] administered and the nurse didn’t take any notice or interest and let it continue. I find that absolutely disgraceful.
“She was doped to the gills just to keep her quiet, if that is what we do to old people in care homes there needs to be major reform.”
However, after hearing two days of evidence, the coroner ruled that, despite the failings of staff, she could not state “on the balance of probabilities” that Daisy’s death was preventable.
She said: “I find that there was a failure by staff at St Catherine’s Care Home to adequately observe Daisy’s condition. Staff could not possibly have carried out competent checks.
“This was not a state that she descended into over a matter of minutes. This would have taken hours or possibly days.
“But none of the medical witnesses have been able to state that, on the balance of probabilities, Daisy’s death would have been avoided had medical care been accessed at an earlier time.”
The coroner noted that she found the evidence of one former staff member at the home, who insisted Daisy was “verbalising that she was fine” earlier that day, “unreliable”.
The court had heard that, in December 2018, Daisy was repeatedly shoved by a member of staff. The staff member was fired from the home and later convicted of assault.
St Catherine Care Home is currently rated ‘good’ by the Care Quality Commission.