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Abbey Court Care Home says lessons have been learned after Bourne pensioner's death

A care home has said procedures and training were 'not robust enough' at the time of a pensioner's death from choking but has put new and improved policies in place.

Joan George was a resident at Abbey Court Care Home in Bourne from August 2015 up until her death at around 11pm on the September 28, 2016. She had choked on a piece of sandwich.

The second day of her inquest today (March 26) heard evidence from Annabel Marshall, deputy manager at the care home and Sarah Mann, associate director of nursing at Priory Adult Care, which owns the home.

Joan George (8079985)
Joan George (8079985)

Marianne Johnson, assistant coroner for Lincolnshire, asked Annabel Marshall if she thought that procedures at the time of Mrs George's death "were not robust enough", to which Ms Marshall replied "yes".

The procedures related to keeping residents' assessments up to date and staff training after it emerged that Mrs George was being fed small pieces of sandwich by care assistant Ahibo Attekeble with her bed at a 45 degree angle and had not seen Mrs George's care plan.

Ms Marshall explained that Abbey Court has "embedded the lessons learned" from Mrs George's death.

Mrs Johnson asked Sarah Mann, who joined the company after Mrs George's death, whether she accepted there were 'inadequacies' in staff training at Abbey Court.

She responded that they were not as robust as they should have been.

Ms Mann told the inquest that Priory Adult Care had improved staff training on how to feed residents correctly and that basic life support refreshers were now given once a year, rather than every three, and that they now included a segment on how to deal with someone choking.

Handovers between staff were also improved.

A new assessment called 'supporting service users with swallowing difficulties' had also been implemented along with a 'much greater focus' on documentation and keeping it up to date.

There was also clearer information produced about each resident so the care assistants were more aware of residents' needs along with a 'resident of the day'.

This sees one resident of each wing at the care home focussed on, making sure everything to do with them is in order.

"It's about putting the residents at the centre of the process," Ms Mann said.

"On that particular day, everything that could be done is done."

Annnette Wakeford, principle practitioner of adult safeguarding at Lincolnshire County Council, told the inquest that she and a team from the safeguarding team had visited the home on a number of occasions after Mrs George's death.

She put forward four recommendations to the care home:

  • Staff would benefit from further training in writing reports
  • Communicating with relatives more effectively
  • Clarification in regards to do not resuscitate orders
  • Further training in writing comprehensive care plans

In response to this, Ms Mann, said that steps were being taken to address all of these recommendations.

Training had commenced into writing reports, relatives meetings were held once a quarter, staff had been made more aware of do not resuscitate orders and that there would be much more cross-referencing between care plans and risk assessments.

Mrs George's family concluded the day's session with an emotional tribute to much-loved Joan.

They said she was "important to us" and explained how devoted she was to husband Frank, her two children and grandchildren along with her wider family.

The inquest continues and a verdict will be delivered by the jury tomorrow.

To read the Mercury's report from the first day of this inquest, click here.

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