Duty of candour probe over care home patient death

Neglect contributed to the death by sepsis of 88-year-old Irene Fenn, an inquest concluded

The Care Quality Commission (CQC) is to investigate how open and transparent a Bupa care home was over the death of a patient there.

Family of Irene Fenn have been told that a national investigator is to be appointed to the case.

There will be another internal CQC hearing this month to see whether safe care and treatment will be included in the investigation.

An inquest concluded that the 88-year-old's death from sepsis in 2022 had been contributed to by neglect at Heathbrook House in Bromsgrove, which has offered its condolences to the family.

The duty of candour is a legal onus on staff to be open and transparent with patients and families when mistakes are made during care.

Mrs Fenn developed pressure sores at Heathbrook House nursing home and one ended up infecting her bone, which led to her death.

An adult social care report found that although the ulcer had been identified on 7 March, the issue was not revisited until 16 March – nine days later.

The report also identifies failures to reposition her and failings in basic hygiene.

Patient notes show no evidence that she received care on four dates.

In a period of two weeks, only one shower was recorded and her teeth were brushed three times.

There is no record of the 88-year-old having had her hair washed for that period.

When Mrs Fenn was admitted to hospital, NHS Herefordshire and Worcestershire terminated her placement at the home with immediate effect due to "clear evidence of a failure of service delivery."

The CQC has now written to the family, stating: "I can confirm, in July 2024, I presented an alleged breach of Regulation 20: Duty of Candour; Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 at an internal criminal enforcement panel.

"At this panel, the decision was made to take this further for forward investigation by our national enforcement team."

Nicola Doughty, managing director of Heathbrook House, had previously stated that on this occasion care fell short of the home’s quality standards.

"Since 2022, we have refreshed training for our teams in wound prevention, wound care management, medication management and sepsis awareness at Heathbrook House.

"We have also introduced a new management team to the home, including a new home manager, deputy home manager and regional director, and have a full team of nurses providing high quality care to our much-loved residents."