The Elms: HC-One admits mistakes unacceptable in care home deaths

Margaret Canham, David Poole and George Lowlett died in 2019

A major provider has admitted "unacceptable mistakes" in the care of three people who died after living at a home, which later closed over failures.

Margaret Canham, George Lowlett and David Poole all died within weeks of each other in 2019 having been residents of The Elms in Whittlesey.

At inquests in Cambridgeshire, coroner Caroline Jones found shortcomings, poor care and issues with record keeping.

HC-One, which ran the home, has apologised to their families.

The home shut down last year and HC-One, one of the UK's largest providers, admitted failings. It was later rated inadequate by the Care Quality Commission (CQC).

David Poole, 74, Margaret Canham, 97, and George Lowlett, 90, were all admitted to hospital with sepsis within a few days of each other in February 2019.

Mr Poole's inquest was the last of the three to take place in front of assistant coroner for Cambridgeshire and Peterborough, Ms Jones, at Peterborough Town Hall this week.

Jeanne Poole, Mr Poole's widow (left), and Kim Arden, granddaughter of Margaret Canham (right), have attended the inquests, alongside George Lowlett's daughter Laura Newell

Ms Jones had already found "shortcomings" after Mrs Canham's death, while she said there were "missed opportunities" to respond to Mr Lowlett's worsening health.

Giving evidence on Friday at Mr Poole's inquest, Dr Jane Douglas, who produced a report, said the 74-year-old had "extremely complex care needs", having dementia and Parkinson's disease.

She said there was a "bowel management plan in place for him", but found there was a "failure to administer medications as prescribed".

In her conclusion, Ms Jones said it was "disconcerting to hear of David being in such frequent discomfort when the solution could have been more straightforward if a doctor's directions had been followed".

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

Record-keeping issues have been highlighted throughout the inquests, and Dr Douglas said it was "very difficult to ascertain" how Mr Poole's fluid intake was being monitored.

Ms Jones said there were "inaccuracies and omissions" in what was recorded, while Friday's inquest heard evidence that nurses were not being told about matters that records said they had been informed about.

She said Mr Poole's care at The Elms was "not of a reasonable standard" and not "safe and effective".

Mr Poole was taken to Peterborough City Hospital on 18 February where he was diagnosed with sepsis.

He recovered enough to be discharged and was moved to Ashlynn Grange Care Home in Peterborough, where he died after receiving palliative care on 24 March 2019.

Ms Jones ruled that he died of natural causes, namely dementia contributed to by Parkinson's disease.

She said that the poor care was not causative of Mr Poole's death.

David Poole's widow called him a "proper gentleman"

She paid tribute to the three families involved, stating the changes "brought through your campaign is remarkable".

She added that the "landscape for care in Cambridgeshire has now changed" following their work.

The inquest heard that Cambridgeshire County Council had placed an ongoing embargo upon HC-One, preventing referrals to their three remaining homes in the area.

The council's assistant director for adult social care, Donna Glover, told the hearing the authority had "spent more time with this provider than any other" and "that level of input isn't sustainable".

She said the council intended to extend the embargo for the next 12 months, which Rebecca Sutton, lawyer for HC-One, said came "somewhat as a surprise".

After a break, Ms Sutton added that HC-One was "shocked and dismayed by the approach taken by the local authority", and expressed frustration that it had been delivered "by a [remote] link in an inquest". 

But Nick Stanage, representing the council, said the decision had been "reached in order to protect lives in Cambridgeshire".

The coroner, acknowledging the "late bombshells" around the embargo extension, adjourned matters concerning prevention of future deaths.

The Elms care home was based in Whittlesey, near Peterborough

After the hearing, a HC-One spokesman said: "We are clear that The Elms should have provided far better care to Mrs Canham, Mr Lowlett and Mr Poole.

"We sincerely apologise to the three families involved for our shortcomings, for their experience engaging with our teams, and for the upset that has been caused. We hope this week's outcomes provide some sense of closure for them."

He said both the home and regional management team "fell far short of everyone's expectations and standards, and did not live up to our values of transparency and accountability", and no longer worked for the company.

He added: "Record keeping has been a major theme in these inquests. The system we use across all our homes has - when used correctly - been proven to achieve the highest Care Quality Commission grades.

"However, The Elms did not use this system correctly which led to unacceptable mistakes in the care of Mrs Canham, Mr Lowlett and Mr Poole."

He said they had improved staff training and were moving to a "fully digital care record system" to "prevent similar mistakes from happening again".