Failings at care homes led to patients’ deaths

Failings in care that led to two unexpected deaths at a Bradford care home and one at a mental health hospital have emerged in an independent inquiry.

The review by regional health chiefs came after the deaths of two residents at Weaver Court residential care home in Idle and one death at Lynfield Mount Hospital’s Highfield Unit.

NHS Yorkshire and Humber has looked at the internal reports into the three “serious untoward incidents” as well as reviewing the unconnected visits by the Care Quality Commission regulator at Weaver Court which saw it given a zero star rating.

The report published yesterday reveals that: l A 39-year-old man with Down’s Syndrome suffocated at the Highfield Unit in April, 2008 after inhaling mashed potato to such a degree that all efforts to save him failed. The risk of him choking had been recognised and dealt with in his care plan, but it happened on the first mouthful of food.

l A 50-year-old male resident at Weaver Court died after emergency bowel surgery in June, 2008. A post-mortem examination found two surgical gloves in his rectum, but this was found not to be the cause of his death. He died of an infection of the colon complicated by a significant degree of ischaemic heart disease. He was known to access the clinical waste bins which contain faeces at the home and this could have been the source of the gloves and a possible cause of the infection.

l A 62-year-old quadriplegic women resident at Weaver Court, died at Bradford Royal Infirmary in November, 2008. She had moved there three years earlier as a temporary measure when a nursing home closed down. She had a history of chronic chest problems and gastro-intestinal problems and was admitted to BRI on a number of occasions and had been fitted with a feeding tube to the stomach. There was a problem with the tube and an overall lack of co-ordination as her complex care involved many different agencies.

As a result of the probe by the strategic health authority a string of recommendations have been made which are expected to be the subject of an action plan put before Bradford Council’s social care improvement committee meeting next Wednesday.

The review has concluded that: l There had been substandard practice in health and social care in relation to the three reported deaths l Action plans were immediately co-ordinated to address concerns raised and improve the service l Significant improvements have been, and continue to be made l The existing Learning Disabilities Commissioning Strategy, once fully implemented, has the potential to avoid the healthcare risks identified in the report.

The report also refers to the rating of Weaver Court by the CQC, which saw it being downgraded in July after failing in every category. The 17 specific areas which needed improvement have since been acted on and the home has recently received one star.

A joint statement issued by NHS Bradford and Airedale, the Bradford Council and Bradford District Care Trust, said: “We are sorry that there clearly have been instances where the expected level of consistent, high quality and co-ordinated healthcare for these vulnerable people was not met.

“We have all learned important lessons. While action was taken immediately in all three cases to minimise future risk and it is recognised that much progress has been made, this report further re-inforces the importance of us all continuing to work closely together to deliver the quality of care our vulnerable people have a right to expect and we have a responsibility to deliver.

“We will act immediately on the recommendations of the review and ensure that the lessons learned are shared widely throughout the health and social care system. We are confident that our Learning Disabilities Commissioning Strategy will deliver quality learning disability services in Bradford and Airedale.”

The full report is available at and