Image source, Family photo

A coroner said it was "disconcerting to hear" about the discomfort of a 74-year-old resident of a care home, which later closed down due to failings.

David Poole was one of three people who had been at The Elms in Whittlesey, Cambridgeshire, to die within weeks of each other in 2019.

A coroner, who also raised concerns in the other cases, said Mr Poole's care was "not of a reasonable standard".

But she said it could not have been considered as causative of his death.

The home, run by one of the UK's biggest care providers, HC-One, closed down last year and admitted failings. It was later rated inadequate by the Care Quality Commission (CQC).

Mr Poole's inquest followed those of Margaret Canham, 97, and George Lowlett, 90, in front of assistant coroner for Cambridgeshire and Peterborough, Caroline Jones.

All three residents were admitted to hospital with sepsis within a few days of each other in February 2019.

Ms Jones had already found "shortcomings" after Mrs Canham's death, while she said there were "missed opportunities" to respond to Mr Lowlett's worsening health.

Giving evidence on Friday at Mr Poole's inquest, Dr Jane Douglas, who produced a report, said the 74-year-old had "extremely complex care needs", having dementia and Parkinson's disease.

She said there was a "bowel management plan in place for him", but found there was a "failure to administer medications as prescribed".

In her conclusion, Ms Jones said it was "disconcerting to hear of David being in such frequent discomfort when the solution could have been more straightforward if a doctor's directions had been followed".

Image source, Steve Hubbard/BBC

Record-keeping issues have been highlighted throughout the inquests, and Dr Douglas said it was "very difficult to ascertain" how Mr Poole's fluid intake was being monitored.

Ms Jones said there were "inaccuracies and omissions" in what was recorded, while Friday's inquest heard evidence that nurses were not being told about matters that records said they had been informed about.

She said Mr Poole's care at The Elms was "not of a reasonable standard" and not "safe and effective".

Mr Poole was taken to Peterborough City Hospital on 18 February where he was diagnosed with sepsis.

He recovered enough to be discharged and was moved to Ashlynn Grange Care Home in Peterborough, where he died after receiving palliative care on 24 March 2019.

Ms Jones ruled that he died of natural causes, namely dementia contributed to by Parkinson's disease.

Image source, Family photo

She paid tribute to the three families involved, stating the changes "brought through your campaign is remarkable".

She added that the "landscape for care in Cambridgeshire has now changed" following their work.

The inquest heard that Cambridgeshire County Council had placed an ongoing embargo upon HC-One, preventing referrals to their three remaining homes in the area.

The council's assistant director for adult social care, Donna Glover, told the hearing the authority had "spent more time with this provider than any other" and "that level of input isn't sustainable".

She said the council intended to extend the embargo for the next 12 months, which Rebecca Sutton, lawyer for HC-One, said came "somewhat as a surprise".

After a break, Ms Sutton added that HC-One was "shocked and dismayed by the approach taken by the local authority", and expressed frustration that it had been delivered "by a [remote] link in an inquest". 

But Nick Stanage, representing the council, said the decision had been "reached in order to protect lives in Cambridgeshire".

The coroner, acknowledging the "late bombshells" around the embargo extension, adjourned matters concerning prevention of future deaths.

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