Man died in Blackpool care home after being given solid food - sparking concerns over future deaths
Terry Manning died in hospital after collapsing while eating a meal
Carers at a Norbreck rest home wrongly said in a resident’s notes that he was being fed a pureed or soft texture diet - before he died after choking on solid food.
Terry Manning, 67, a former council passenger assistant who was known to eat quickly, died at Blackpool Victoria Hospital two days after collapsing at Haddon Court Rest Home while eating a meal, causing him to go into cardiac arrest and suffer brain damage due to a lack of oxygen, an inquest has been told.
Andrew Cousins, assistant coroner for Blackpool and Fylde, has now warned of more tragedies unless workers at the home, which can accommodate up to 33 older people, who may have dementia, stop copy and pasting residents’ records.
He said: “Mr Manning was not being fed a pureed or soft texture diet, and entries to this effect in the care records are errors in the record keeping. These errors have been caused by carers carrying forward the details of records relating to other residents from entries made on the records of those other residents.
“It was noted in the evidence that erroneous record keeping had taken place over a period of time and involved multiple carers.
“It was caused by carers transposing the records of one resident into the care records of another, leading to inaccuracies.
“I found that these matters gave rise to a risk of further death as the record keeping was inaccurate and did not reflect the foods being given to Mr Manning…”
Manning, who was originally from Devizes in Wiltshire and had dementia, moved to the home on June 29 last year, the inquest was told, and choked on October 22. He died on October 24.
His death was accidental, Cousins concluded, and caused by a hypoxic brain injury, out-of-hospital cardiac arrest and choking on a ball of chewed-up food.
Frontotemporal dementia, a rare type of the disease, was listed as a contributing factor.
Bosses at Haddon Court said “all staff have been reminded about the importance of accuracy in record keeping”.
In a letter to Cousins, a director, whose name has been redacted from records, added: “We have particularly reminded the staff about the risks of using what is termed the ‘repeat functionality’ of the software in question, and to ensure that records are checked for accuracy after use of this feature.”
The director said the home had contacted the software’s maker, Person Centred Software, and was told: “The ‘repeat functionality’ is designed to make repetitive tasks and care actions quicker and easier to record. That’s very beneficial if multiple residents are taking part in one activity - eg physical exercise.
“A carer may have supported multiple residents with the same care, and thus (would) benefit from being able to repeat the same action for one resident to another; there remains however the responsibility of the user to ensure that the care record reflects the care provided.
“It should also be noted that the care is record(ed) ‘post the care interaction’ and would not therefore have been used to determine how a resident will have their food prepared.
“It is important the carers are encouraged to record the most accurate and person-centred records as possible. Based on your input, we will review the repeat functionality in detail and consider certain categories of care to be removed from the repeat functionality. That would force users to individually report the details for each resident in those selected categories.”
The unnamed director said they believe “robust measures” have been taken to “ensure records at the home meet the standards rightly expected from legal, professional and regulatory perspectives”.
They added: “We have also responded as fully as we are able to in relation to bringing this matter to the attention of and influencing the software provider. I understand that they are currently working on the functionality that will help to reduce the risk of erroneous reporting.”
The home, run by Haddon Court Limited, was last inspected by the Care Quality Commission in October.
The health industry watchdog gave it an overall rating of “good”, the same ranking as four out of five key areas: safety, effectiveness, levels of caring and responsiveness.
For the fifth, linked to leadership, it said the accommodation “requires improvement”, adding: “Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.”
The Blackpool Lead asked the home a number of questions, including how the staff involved in the copy and pasting of records to make them erroneous have been disciplined and how it can guarantee no more mistakes of the kind will be made.
The firm, run by John and Claire McGailey, according to Companies House, did not respond.
John McGailey previously told The Gazette that Manning was not “subject to a diet of an altered texture” and Cousins “found no neglect by the care home”, with “no aspect of care provided” contributing to his choking.
He admitted to “recording ‘errors’” but said they “did not contribute to the choking incident in any way”.
He said: “Haddon Court has always utilised a separate process for preparation and (the) serving of diets that require altered texture which removes the risk of anyone being given food of an unsuitable texture…”
McGailey added: “We have previously expressed our condolences to the family of the gentleman concerned.”
The specific software in question was not named in coroner documentation but Person Centred Software has described mCare on its website as the “care sector’s most widely used digital care planning system”.
It claims to save “each carer, nurse and home manager over three days per month compared to paper-based records and other digital systems” and boasts “icon-driven care notes with over five million care interactions recorded daily - or an average of 58 notes per resident, per day”.
Person Centred Software did not respond to a request for comment.