Care home resident died after CPR 'gross failure'

The coroner said he was concerned further deaths could occur if concerns were not addressed

A care home patient died after a "gross failure" of a nurse who "forgot her basic training" and performed inappropriate CPR, a coroner has said.

Dr Nicholas Shaw, assistant coroner for Cumbria, said he was concerned about the risk of future deaths at Westmorland Court home in Arnside after the death of James Reginald Capstick.

Dr Shaw said the 83-year-old suffered 10 fractured ribs when he received CPR when he was not in cardiac arrest and contributed to his death.

The care home has been approached for comment.

The coroner has issued a prevention of future deaths report highlighting concerns into the circumstances of the death.

The report has been sent to the home which has 56 days to respond to concerns raised and detail any action it is taking.

'Neglect'

In his report the coroner said the 83-year-old had many episodes when he became unresponsive and an emergency call was made by the home in December 2021.

But the coroner said there was "great confusion" between the call handler and the nurse in charge of the home, who is not named in the report.

"This confusion led to over 20 minutes of chest compressions being continued on Reg despite clear signs of life - basic checks to confirm this were not carried out," he said.

During an inquest held earlier this year Dr Shaw found that the "massive chest injury" suffered by Mr Capstick caused respiratory problems, including pneumonia.

Delivering a narrative conclusion, he said that while these were successfully treated, the combination of injury and illness led to his death on 1 October 2022.

Dr Shaw said: "The continuation of chest compressions by a registered nurse in the face of clear indications that her patient was not in cardiac arrest but alive was a gross failure in basic care and can be classed as neglect."

The coroner said during the inquest that he had been told the nurse was "stepped down" from duties for a short while and returned to work after further training.

In his report, which was also sent to the Nursing and Midwifery Council (NMC), he asked if a referral made to them about the nurse had been closed.

When approached by the BBC, Lesley Maslen, executive director of professional regulation at the NMC, said the coroner's documents were being reviewed.

She added: "We will provide a response to the coroner, including details of whether any appropriate action is needed."

Safeguarding referrals

Dr Shaw said evidence given by a GP during Mr Capstick's inquest said although care at the home had improved since his death, he still had concerns about the care given to residents.

The documents show three safeguarding referrals were made to social services regarding the death - one by ambulance crews after CPR was given, one by friends after he returned to the home and a third when he returned to hospital in September 2022.

Mr Capstick became ill and was taken by ambulance to the Royal Lancaster Infirmary, where he died.

Dr Shaw said: "The admitting crew were very concerned by his appearance, apart from illness he was said to be dirty, unkempt and emaciated and dehydrated with a dry, caked mouth that did not appear to have had any recent care."

While the first two referrals were closed, the third remained open, Dr Shaw said.

Westmorland and Furness Council, which is responsible for social services in the area, said it had been made aware of the coroner's report.

A spokesman said: "Working with relevant partners, we continue to pro-actively work with the care home."

The Care Quality Commission watchdog has also received the report.