Rachel Johnston: Care home must take action 'to prevent future deaths'

Rachel Johnston died in October 2018

A care home must take action to prevent future deaths after a disabled woman died when she returned from hospital having had all her teeth removed.

A coroner concluded neglect contributed to Rachel Johnston's death and the 49-year-old would probably have survived if staff acted sooner.

Senior coroner David Reid has sent a report to the owners of Pirton Grange, near Worcester.

The home said systems have since been improved.

Mr Reid's report to prevent future deaths has been sent to the Care Quality Commission (CQC) as well as lawyers for both the home and Miss Johnston's family, following the inquest's conclusion.

He raised concerns about a lack of adequate internal investigations or disciplinary procedures to identify the failings of nurses and no policy was in place to suspend staff while investigations were carried out.

Miss Johnston's teeth were surgically removed at Kidderminster Hospital on 26 October 2018 because of severe decay.

However she fell ill after returning to the care home and, when an ambulance was called two days later, her "entire brain had been starved of oxygen", her inquest heard.

Her family decided to withdraw life support and she died two weeks later.

Miss Johnston's mother Diana said "justice had been done" through the coroner's investigation

Mr Reid said "gross failures" by two care home nurses who did not record and properly monitor Miss Johnston's condition, contributed to her death.

Care home manager Jane Colbourn, giving delayed evidence on Friday, said the two nurses carried on working at the home because they "knew residents well".

They were only referred to the NMC by care home owner Holmleigh Homes on 23 February, the firm's quality assurance manager told the hearing.

In his report, Mr Reid said prevention action needed to be taken and the firm had until 21 May to respond.

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Holmleigh Homes said changes have been made to improve systems and procedures and staff given additional training in all key areas highlighted by the case.

In a statement after Friday's hearing, Miss Johnston's mother Diana said "justice had been done" through the coroner's investigation and she was relieved the nurses had now been reported.

"Nothing can bring Rachel back, but at least we can go forwards knowing her death has not been ignored," she said.