Coroner calls for care home reviewBy Laura McCardle
May 03, 2012
A coroner has called for a care home to review its staff training and equipment in life-saving care.
Peter Bedford used Rule 43 of the Coroners Rules to ask Parkside House Nursing Home to evaluate the issues at the inquest on Tuesday, April 17, into the death of 94-year-old Florence Steiner.
The move came after he heard evidence from paramedic Victoria Wood, who raised concerns about staff and their equipment after being called to the Parkside Road home in Southcote on Sunday, December 11, last year.
Mrs Steiner was admitted to the home days earlier on Thursday, December 8, after being discharged from Royal Berkshire Hospital (RBH).
Upon her arrival she was noted as being “quite frail” and that she had suffered with heart failure and problems with her kidneys.
The inquest heard from Shaiby Sebastian, a nurse at Parkside, who said the emergency services were called on the morning of Mrs Steiner’s death when she noticed her breathing had become “really shallow” and “very slow”.
She said a nasal cannula was applied and that both CPR and chest compressions were carried out by she and other staff when Mrs Steiner’s condition deteriorated until the ambulance crew arrived.
But when Mr Bedford took Miss Wood through a statement she made at an earlier date, the inquest heard chest compressions were only started after the paramedics arrived.
Miss Wood then expressed concern that the nurse carrying them out was doing it too slowly before taking over from the member of staff.
She told the inquest she was also unhappy with the equipment staff at the home had used to assist Mrs Steiner with her breathing.
Miss Wood said: “The mask didn’t look right to me, just the mask itself.
“[There was] no seal so when they ventilated a patient not much air was staying in.”
The inquest heard Miss Wood was so worried about the practices at the home that she officially voiced her concerns after she and her colleague had taken Mrs Steiner to RBH.
Mrs Steiner died at RBH on the afternoon of Sunday, December 11, last year.
Manager of Parkside House Nursing Home Lizzy Gardo responded to Miss Wood’s concern by telling the inquest that all staff receive yearly training and that all oxygen equipment used in a bid to resuscitate patients is recommended for that use.
Mr Bedford recorded a narrative verdict and said: “CPR was not started as promptly as it could have been, that the provision of oxygen was not ideal due most likely to the quality of equipment available, having reached the conclusion about the CPR that training of staff is an issue that I believe may have been a factor.”
Rhona Mcleod, regional director, South East Bupa Care Services, said: “We will review the coroner’s comments closely and decide how best to address his recommendations.”