The Elms: Missed opportunities in man's care, says coroner

George Lowlett was not provided with a reasonable standard of care, a coroner said

A 90-year-old man was not given "a reasonable standard of care" in his final days at a care home, a coroner has ruled.

George Lowlett was one of three people who lived at The Elms in Whittlesey, Cambridgeshire, to die within weeks of each other in 2019.

There were "missed opportunities" to respond to his worsening health before a hospital admission, the coroner said.

The home closed down last year after being rated "inadequate" by the CQC.

Assistant coroner for Cambridgeshire and Peterborough, Caroline Jones, concluded that Mr Lowlett died of natural causes, namely sepsis contributed to by pneumonia, at Peterborough City Hospital on 18 February 2019. 

But it was "possible there were earlier opportunities to seek medical intervention", Ms Jones said. 

Mr Lowlett had been found unresponsive in his room by his daughter the previous day, having been diagnosed with a chest infection a few days earlier, the Local Democracy Reporting Service said.

Ms Jones said the GP's advice regarding when to seek further medical attention "was not adequately recorded or communicated" by carers at the home.

She said it was not possible to say if the outcome would have been different had he been admitted to hospital sooner, but he would have had a "somewhat better chance" of recovery. 

The Elms closed down last year, with HC-One admitting failings

Witness statements from Mr Lowlett's daughter, Laura Newell, and some of his care records suggested he was visibly unwell and deteriorating in his final few days at The Elms.

But other records and witness statements from one of the care home's nurses involved in his care, Coleta Bartolome, suggested he appeared well despite his chest infection. 

The inquest heard "two different versions of events", Ms Jones said, and discrepancies in his records made it difficult for the court to "establish precisely the seriousness" of his condition. 

Record-keeping "was piecemeal" with staff "lacking clarity" about when or where to record updates, the coroner said.

Margaret Canham, David Poole and George Lowlett died in 2019

During Mr Lowlett's inquest, watchdog the Care Quality Commission (CQC) apologised to his family for failing to follow their own processes in relation to a complaint after his death.

His inquest is the second of the three residents' hearings to be heard at Peterborough Town Hall, after the coroner found "shortcomings" following Margaret Canham's death.

An inquest into the death of another resident, 74-year-old David Poole, continues.

Cambridgeshire County Council has placed an ongoing embargo upon care provider HC-One preventing referrals to their three remaining homes in the area.

HC-One previously said their "priority" was that residents received the "very best care" and that "a lot has changed" since 2019.