Neglect contributed to the death of a musician who did not ‘see the sunlight’ for ten months whilst at a care home, a coroner found.
Paul Chin, 47, from Margate, Kent, was admitted to hospital in October 2014 with what was later diagnosed as a relapse of meningeal tuberculosis.
In January 2015, Paul was discharged from hospital to Woodchurch House care home in Ashford, Kent. He died 10 months later of sepsis and an acute, sudden kidney infection.
The coroner heard that whilst he was in the care of Woodchurch House, staff treated Paul as having no prospect of rehabilitation. As a result, staff failed to assist him with his rehabilitation potential and Paul did not set foot outside his room for 10 months.
Despite being on a controlled diet to manage his weight, the home provided Paul with an unhealthy diet with foods high in fat and sugar. He was socially isolated being bedbound on a floor where elderly patients with dementia also lived. He was not provided with a wheelchair or other vital equipment required for his rehabilitation.
Due in part to his immobility, Paul was on a catheter for the entirety of his stay at the home. In their evidence at the inquest experts suggested, in line with NICE guidance, that this continued catheterisation increased the risk of Paul contracting a urinary tract infection (UTI) and sepsis. Staff at the home failed to trial a period with Paul not using a catheter. He died of sepsis, caused by a UTI, on November 26, 2015.
Following over two weeks of evidence including from care home workers and experts, the coroner concluded that vital sign observations had not been conducted on the night prior to Paul’s death. She found that this amounted to a gross failure to make simple basic checks on a dependent person, resulting in a failure to call medical assistance which could have saved Paul’s life.
Despite the well-recognised risk of infection linked to catheterisation, staff had failed to manage this risk through appropriate risk management and escalation plans. This failure contributed to Paul’s death. The coroner also found that other risk assessments were missing, and care plans contained misleading and inaccurate information. Moreover, she held that there were insufficient nurses on duty on the night Paul died.
Following the inquest Paul’s family said: “Paul’s unnecessary and avoidable death has left us both heartbroken and angry. We believe the way Paul was treated in the 10 months he was at Woodchurch House care home was inhumane. He was not allowed out of his room once in 10 months despite our constant pleas. Paul was unable to feel the fresh air on his face and was instead confined to a bleak room as if it were a cell. We remain extremely angry about this and the fact that he was placed on a catheter for that whole time.
“Fighting for better treatment for Paul while he was alive was incredibly difficult because the care home and other agencies responsible for his care continually shifted responsibility to each other. The blame shifting continued following Paul’s death and during the inquest. We feel nothing but contempt for KCC social services, the owner and the management staff of Woodchurch Care home for how they failed Paul.
“There are too many people suffering like Paul did in care homes and we would urge their families to never give up fighting for the improved care their loves ones deserve. Finally, we would like to thank Nancy Collins and our legal team at Hodge Jones & Allen for their years of dedication in trying to get justice for Paul.”
Nancy Collins, Partner at Hodge Jones & Allen, who represents the family, said: “Paul was a vulnerable adult with cognitive difficulties who was dependent on others to facilitate and encourage his rehabilitation. Unfortunately, the failure to provide him with the support he so badly needed reflects the poor standards of care provided to so many in our crumbling care system.”