I’ve written a number of posts reporting Peter’s second inquest now, a quick recap incase this is the first one you’re coming to. There’s one about how he came to be in the care of the Priory Group here, one about support worker Siobhan Cator and her understanding of 1-1 supervision and refusal to have her statement altered by the Priory Group, one about Peter’s SALT assessment, his Eating, Drinking and Swallowing Plan and staff’s understanding of it, one about the events that took place for Peter when he was resident in the home in April 2018 and one providing an overview of the coroner’s conclusion here.
In this post I want to address what the court has heard about the incidents of 15 and 21 May 2018.
On the 15 May it was recorded in two separate meal records that Pete coughed when eating, but no further action was taken. Deborah Cuzner, the Deputy Manager, was supervising Peter that day and said that the cough didn’t concern her as he was just clearing his throat. The coroner wanted to know whether Ms Cuzner had noticed that Peter had been given food in contradiction to his care plan that morning, and insufficient supervision, also in contradiction to his care plan.
C: Did you note that? Banana sliced and cup of tea 15mins, did you note that when you filled in quiche?
DC: Unfortunately because I was on the floor I’d have been rushing around doing notes
C: So you didn’t pick up two other snacks that day didn’t comply with the food allowed, or the 1-1 supervision time?
DC: Unfortunately no
C: so when completing records as Deputy Manager, he had slight cough and you didn’t look through to see what else he’d had that day and whether there were any other problems at all?
When the coroner took Ms Debbage, the Speech and Language Therapist to the care home notes for that date she said one of two things could be happening. She thought it might have been that the quiche Ms Cuzner gave Peter for lunch was dry and crumbly and that caused coughing, or secondly as coughing occurred two days running it may have been an indication of deterioration of Peter’s swallowing skill level. She said if the cough continued the SALT plan may need to be reconsidered and that she would expect Peter to be closely monitored.
The court was taken to the home’s records for 21 May 2018 on a number of occasions. This was the day when Peter was taken to hospital having aspirated. He died the next day. I believe I’ve managed to catch an accurate record of what was written in the records, as they were shared over the week.
In the food diary it’s recorded that Peter had Readybrek and a cup of tea for his breakfast, yoghurt and sliced banana and a cup of tea for a snack, shepherd’s pie and veg for his lunch and a cup of tea, diabetic biscuits soaked in milk and a cup of tea for a snack and nothing for a tea time meal as he was too unwell.
It’s a little hard to follow without seeing the records but I believe it was recorded he only ate a small amount of the biscuit snack. In a column for concerns it was recorded at lunchtime he had some coughing but once his throat was cleared all was fine, and number one on the choke scale, but by the afternoon its recorded that Pete was not keeping anything down so a doctors appointment was made for 16:30.
Then there appeared to be a fuller account in the daily notes, written by Suzanne Maunder, as follows:
13-15:00 For lunch Pete had Shepherd’s Pie with veg. Pete did cough while eating and brought some food back up, but once he’d cleared his throat he was dine. Pete then continued and finished the rest of his meal with no concerns. After lunch staff made Pete a cup of tea. Pete stayed sat at the table even after he’d finished and staff found some magazines for Pete to look through.
15-17:00 Mid afternoon snack staff made Pete his diabetic biscuits soaked in milk but Pete was bringing up a large amount of phlegm and was then soughing up anything he ate or drank. Pete was made an appointment at the doctors for 16:30 and was taken by Rio. Prescribed Lansoprozole but waiting to hear back from pharmacy as already taking similar.
17-19:00 Pete was given his tea time meds with a yoghurt and Pete coughed/sicked it all straight back up again. Staff then gave Pete a small drink of weak squash and Pete brought that straight back up as well. Staff didn’t give Pete any tea/food. Pete has since been sick twice more but it is just phlegm. He seems ok in himself, just a bit sleepy.
In questioning from the coroner Gemma Peloe, said she couldn’t recall what shift she was working but she was working as Team Leader that day. She doesn’t remember anything from the morning but did remember the afternoon. Asked by the coroner to tell the court in her own words what she remembered she said:
GP: I remember Peter being sat on the chair as you go into Woodcroft, think it was on the right. He was sat there and he was coughing up like a clear, like a raw egg kind of consistency. Occasionally, he sounded very gargley, but he seemed, even though he was doing that, he seemed well in himself. When he wasn’t making that noise, when he wasn’t bringing it up, he was quite happily looking at his magazines and walking around and being his normal self
C: so he was coughing, but not all the time?
GP: Yeh [fuller answer – didn’t hear]
C: you said otherwise he seemed well in himself?
GP: I know there was coughing, but when he came back from the doctors he was walking around
C: how was he when you first saw him?
GP: He was sat in a chair
C: Was he coughing then?
GP: Not straight away, he was coughing, then he’d stop. He was coughing, there was a gurgling noise, he was bringing phlegm up
C: So from the time you were there in the afternoon you remember him coughing and bringing up phlegm?
Gemma Peloe went on to tell the coroner that she didn’t know who made the doctors appointment but it would be a decision for the Manager or the Deputy Manager, but Rio Horne (who was working in the adjacent bungalow to the one Peter lived in) took him to visit the GP at 16:30.
C: When Rio took Peter to see the GP was there discussion about what she was to tell the GP? Or whether she was to take the care notes so the doctor could see what the concerns were?
GP: I don’t recall. I mean she would have said what was going on, that’s why the doctors appointment had been made, and the doctor done all of her checks that I’m aware of.
C: Is it usual to take the care notes when a resident goes to see a GP or not?
GP: Not that I’m aware of, the doctors is pretty much across the road from the care home. Not that I recall
C: Alright then. Mr Seaby comes back from seeing the GP, you make a call about medication, how is Mr Seaby at that time?
GP: He seems, its really hard to explain, even though he’s coughing and there’s this gurgling noise and the phlegm, he seems well in himself. He was still, between episodes of it, he was still walking around at times, and smiling and he just seemed well in himself.
Mr Cridland put the evidence from the police investigation to the Deputy Manager, Deborah Cuzner. He suggested that there as no-one available to provide Peter with 1-1 supervision at lunchtime.
SC: So it’s fair comment when you look at that its likely no one was providing 1-1 supervision to Mr Seaby at lunchtime on 21 May 2018?
DC: There’s no one admitting to it, or documented it, but there were people on staff who should have provided 1-1
SC: Well the only person who could have done it was Ms Peloe. You also agree don’t you that the presence of that carrot unmashed 2cm in diameter… that his food wasn’t provided that lunchtime in accordance with his care plan?
DC: Unfortunately yeh, I don’t know where the carrot came from, but yeh.
The coroner in her conclusion stated:
At lunchtime Ms Maunder sat next to another resident she was giving 1-1 supervision to that day. She said she sat opposite to Peter, there was no other member of staff in the dining room, and Peter was not being given 1-1 supervision during his lunch in breach of his care plan.
I find Peter was not given 1-1 supervision at this meal, which is in breach of his care plan.
The blog post about the coroner’s conclusion contains more details about what she found in relation to 21 May 2018.
It covers the insufficient information given to the GP Dr Garalevicience, and the discrepancies between Ms Medler’s written statement, about the timings of the 111 and Out of Hours GP telephone calls, and her oral evidence to the court.
Peter was taken to the GP by Rio Horne, a support worker from the other bungalow who didn’t often work with Peter and who had not set eyes on him that day before coming across to take him to the GP. Rio did not take any records, notes or written account of events with her. No explanation was offered for why one of the carers who had been working with Peter, either Suzanne Maunder or the Team Leader Gemma Peloe, didn’t take Peter instead. The GP’s evidence was that had she been given the full picture, as reported in the daily notes, at the time of her appointment she would have taken a different course of action, she would not have given a working diagnosis of reflux, and instead she’d have been sufficiently concerned about Peter’s very real risk of aspiration that she’d have contacted the hospital to arrange his admission for close monitoring and antibiotics if required.
Ms Medler was one of two overnight support workers on shift on the night of 21 May 2018. She had only joined the home 6 months earlier, about the same time as Peter. Asked about her qualifications and experience by the coroner she said:
At that point I was just coming off maternity, previous to that I’d done some care experience working with people in their own homes. I didn’t have any formal qualifications at that point. When I joined Oaks and Woodcroft I did some e-learning and was due to continue with training, but I left in November of that year.
She told the coroner she only worked nights, and on questioning from Mr Cridland it became apparent she only worked two shifts, nights a week. She also told Mr Cridland that Per Oberg was less experienced than her, had been there less than six months and she didn’t think he often worked nights. Mr Oberg was working in Peter’s bungalow, Woodcroft, that night and Ms Medler was working in the other bungalow, Oaks. The court heard no evidence from Mr Oberg in either of Peter’s inquests, although a note he wrote in the records was read.
Ms Medler told the court that Peter being ill that day was mentioned to her at handover and that shortly after their shift started Mr Oberg contacted her concerned about Peter. This is an extract from her questioning by Mr Cridland:
SC: So Per was working in the other bungalow, you say cant remember exact time but not long after your shift started… between 7.30pm and 8 o’clock, you say you went to see Mr Seaby. You observed him sitting in a chair and he was quite sleepy… you called 111…. you say both Per and you kept a phone with you [to receive a return call from them]
SC: So you didn’t miss a call, you say you cant remember what time, but between 10 and 11 o’clock due to increased concern you rang 111 back, and they then told you to call an ambulance?
SC: So the account in your witness statement is two calls, by you, to the 111 service. One between 7:30 and 8 o’clock, because Per had concerns about Mr Seaby, and then another between 10:30 and 11pm because M Seaby had deteriorated, was having breathing difficulties and was pale in complexion?
SC: That account, two calls by you, one just before 8 o’clock, one between 10 and 11pm to the 111 service, the second because you were concerned Mr Seaby had deteriorated, is not a correct account is it?
AM: It is not. At the time when I was trying to make the statement I was trying to think back. I think the second call I was thinking of was the call from the GP when I then went back over to Mr Seaby and saw how he was presenting
SC: We now know there was one call to 111 at 8:53 in the evening. We know they tried to call back at 9:16 that evening, and called back again at 9mins to 11 that evening
Ms Medler was unable to explain to the coroner why they did not receive the return call from the out of hours GP, made just 20mins after the first contact. She also was unable to explain why no chasing call was made by the staff at the home. She told the coroner that she had not used the phone in that intervening period, she did not know whether Mr Oberg had, but she had no explanation for why it was busy.
However the court also heard the transcripts from the 111 calls and the Out of Hours GP calls, read onto the record by two court staff. In the second call Ms Medler says to the GP that she had spoken to her manager and that Peter had been to the GP that day. She was not questioned about this, but I’m left thinking that is one possible explanation as to why the GP could not speak to the care home staff when they returned the call, because the line was engaged, as April was speaking to Deborah Cuzner. We will never know.
In the first 111 call Ms Medler when asked the reason for the call says:
Erm, Peter is erm, seemingly very unwell, he’s just been very sick, his hands have gone purple, he has a number of medical conditions erm, his complexion is very grey, yellow
She tells the 111 call handler Hannah, that Peter has been vomiting, that he also has diarrhoea. Asked if he has pain in the abdomen she says:
Erm. I think he has, oh he’s trying to be sick again, erm, he sounds like he’s in quite a lot of pain. He has been to the doctors today, what did they say at the doctors? Sorry, I’m just trying to find his records
She went on to say Peter was holding his tummy and his neck and was bent over. A little later the handler asks:
111: OK, is he so ill he’s stopped doing all of his usual activity?
AM: Erm, yes
111: Has he been able to watch TV or anything if he wanted to?
AM: No, he’s kind of looking at me like help
111: OK, oh bless him. Has he developed new marks like bruising or bleeding under the skin?
AM: No, but his hands erm, his fingers have gone bluish purple
111: Blueish purple, okay, is that a new mark or is it his whole hand that’s gone like that?
AM: his whole hand
Later Ms Medler confirms to the call handler that Peter had become more breathless than usual since the problem began. She is then told that 111 would advise for him to speak to a primary care service within the hour, and that the 111 service will transfer the details to the out of hours GP service. She is advised that if there are any new symptoms, or if his condition gets worse, changes or they have any other concerns to give them a call back.
That was the call made by Ms Medler at 20:53. We know a return call 20mins later was missed by the home, and that the Out of Hours GP Dr Berber eventually got to speak to someone at 22:51, after trying the home again.
Ms Medler answers the call and makes her way over to Woodcroft, Peter’s bungalow [leaving residents in her own unattended, as there were no other staff on duty]. She tells the GP that she’s spoken to her manager and Peter had visited the GP in clinic that day, and she later reads from his notes to her. She tells the OOH GP:
AM: She [Dr Garalevicience, Peter’s GP from earlier that day] suggested that [gastric reflux] might be why he’s being sick but I’m here now, he’s still, his stomach is still heaving, his hands are still purple, that was one of our big concerns, that his hands keep going purple, well they are a very purple grey colour.
Later in the conversation the OOH GP asks if Peter has had chest pain at any point?
AM: Not that I know of, erm, he was holding his stomach but not his chest
DrB: Ok, is he feeling really poorly?
AM: He looks awful if I’m honest. He doesn’t look himself at all, he’s got quite a greyish complexion.
Dr Berber asks if he’s clammy and April says he’s not but his chest is cooler than normal, but not cold. She goes on to say his feet are purple as well and Dr Berber says that he needs an ambulance and asks Ms Meddler if she’s comfortable phoning one. She is, and does so immediately. The East of England Ambulance Service arrive at the home at 23:08, after Ms Medler has sent Mr Oberg out into the road to flag them down as they were having some difficulty finding the home.
The court also heard evidence from the GP expert, Dr Bint, that he thought the 111 protocol being followed on the first call was incorrect and that an ambulance should have been called for Peter on that occasion. There was no further interrogation of that.
The coroner found this in regard to Ms Medler’s evidence:
C: I do find that the information in the second call with the GP reflected information provided in the first 111 call, and that the evidence provided in the first written statement of Ms Meddler did not reflect what was in the 111 call and Out of Hours GP records.
Throughout the week we heard of several inconsistencies between what was recounted in records, versus what the Priory staff recounted in their statements, in addition to these events. There have been the discrepancy between how many times Peter was sick, and whether he was sick; whether he was coughing or simply clearing his throat; the accounts of the size of food and what food he choked on in April; the discrepancy between the events told to the social worker, written in the home records, and reported to the county council in the incident report form; and within that the discrepancy between the 6 backslaps reported to 111 and the lesser number elsewhere.
We also heard some consistencies between staff, such as about the informal way in which the home was run to make it homely for residents, and the ‘egg white consistency’ of Peter’s phlegm on the 21 May 2018.
On Wednesday we heard from Siobhan Cator, a former support worker, who gave evidence to the court that the reason they only had her police statement was because she refused to sign a statement with the changes that the Priory wanted to make to it.
Peter’s inquest has now concluded but I will write at least two more posts, one about record keeping and decision making, and one about the evidence given to the court by Sarah Mann about changes made and why they felt no Prevention of Future Deaths report was required, and the coroner’s decision to issue a PFD on three counts. Those will be next week at the earliest.
I’ll finish with the statement Peter’s brother Mick, gave after the conclusion yesterday:
“We were really disappointed with the conclusion of the last inquest. We felt like this didn’t answer all our questions and we didn’t get the conclusion that we wanted or felt like Peter deserved. Although the idea of a second inquest was daunting, we felt like we owed it to Peter to have a second inquest, to get justice for him. We loved our brother Peter dearly, he was a lovely, fun, cheeky chap and Karen spent her whole life caring for him. We hope that lessons are learnt by both Norfolk County Council and the Priory Group to avoid anything like this from happening to another vulnerable individual like Peter.”