Bernard Lyon’s family weren’t aware of the problems at the care home. He later died in hospital from a lung infection
Hyde Care Home(Image: Google)
A coroner has raised urgent concerns over the care of a vulnerable pensioner who was sent to a failing nursing home which relied on agency staff who ‘struggled to grasp English’.
Manchester South coroner Alison Mutch warned there is a ‘risk that future deaths could occur unless action is taken’. Bernard Lyon died of a lung infection aged 85 at Tameside General Hospital on January 30 last year.
Four weeks earlier Mr Lyon, who had difficulty swallowing and needed full-time care, was sent to Hyde Care Home in Gee Cross, Tameside. At the time the home was subject to a quality improvement action plan due to concerns over the standard of care it was providing.
In a prevention of future deaths report Ms Mutch wrote the home had ‘too few managers to be effectively managed’ and ‘relied on agency staff who… struggled to have sufficient grasp of the English language to understand instructions and communicate with residents’.
Ms Mutch said Mr Lyon’s family weren’t aware of the problems and had they known it was ‘probable’ they wouldn’t have chosen the home. While at the home Mr Lyon’s modified diet ‘wasn’t always adhered to’ due to a ‘shortage of managers and communication issues between the management team and staff’.
On January 22 he went to Tameside General Hospital where he was found to be ‘very unwell’ with sepsis. Because A&E was very busy there was a delay in giving him antibiotics, Ms Mutch said.
His condition deteriorated and he died on January 30. A post-mortem found he had microscopic traces of food in his lungs which had probably led to him developing aspiration pneumonia, a severe infection caused by bacteria entering the lungs.
At an inquest at Stockport coroner’s court in March Ms Mutch gave a narrative conclusion that Mr Lyon died ‘died from the complications of aspiration pneumonia which developed as a consequence of aspiration of food whilst resident of a nursing home’.
In a prevention of future death report sent to the Department of Health and Social Care, Tameside council and the Care Quality Commission, Ms Mutch outlined seven matters of concern. They included concerns over the care home, a lack of a process to let families know when care homes are under an improvement plan, ‘significant delays’ in Mr Lyon being handed over by paramedics to the A&E department, delays in antibiotics being administered due to the A&E being ‘extremely busy’ and concerns over delays in patients being discharged from hospital due to a lack of community care.
A Tameside council spokesperson said: “Our priority is to keep residents receiving care and support safe and well. As part of the Tameside Adult Safeguarding Partnership Board, we work closely with the coroner and our partners to ensure all recommendations are acted on.”
A DoHSC spokesperson said: “Our deepest sympathies are with the friends and family of Mr Lyon. We consider all PFD reports carefully and will respond in due course.”
A CQC spokesperson said: “We’re aware of the coroner’s report into the sad death of Bernard Lyon and our condolences go out to his loved ones. We are reviewing the report to determine whether there is any regulatory action we may need to take.”
Hyde Care Home has also been contacted for comment.