There were so many issues that emerged during the court of Peter’s second inquest. I can’t blog about all of them, but I wanted to just focus on record keeping and decision making at Oaks & Woodcroft, before the final post which will focus on the Prevention of Future Deaths evidence given by the Director of Quality at the Priory Group Adult Care, Sarah Mann.

As is so often the case in inquests, the record keeping evidence presented to the court is contradictory, incomplete, inaccurate and on occasions illegible. How this level of complacency can be so routinely accepted by staff who are caring for dependent people requiring support I don’t know.

What I do know is that The Priory Group have received numerous Prevention of Future Death reports in the years I’ve been reporting inquests, and many of them have related to inaccuracies and omissions in record keeping.

The coroner discussed the recording of 1-1 supervision of Peter at mealtimes with Gemma Peloe, one of the two Team Leaders. She seemed quite vague in what was required. Mr Cridland picked this up in his questioning of Gemma Peloe too:

SC: Were you given any training in how to complete these records?

GP: I don’t think there’s any specific training in how to complete them

Mr Cridland also asked support worker, Siobhan Cator, how she knew what to record in the notes.

Mr C: Were you given any training with regards to the completion of resident’s care records?

SC: No you read past ones really. You saw what other people had written so you get the format of the day… you included stuff important is what I’m trying to say. No we weren’t, it was just to record their day.

The coroner picked the issue of record keeping up with the Deputy Manager, Deborah Cuzner. She was particularly focused on what would be recorded in the 1-1 column at mealtimes, whether it would be all supervised time of Peter, including the required 10min gap between eating and drinking, and the 10mins afterwards:

C: Part of his daily records, has his meals, the amount consumed, concerns and 1-1 time. What was your expectation as to what should be recorded in 1-1 time?

DC: Any 1-1 time they’ve spent with him, through eating, through the 10mins and the 10mins after

C: So you’re of the view it would include those two periods of 10mins?

DC: Yes

C: We heard from Ms Peloe this morning she disagreed with that, it was just time of eating or drinking but that’s not your view?

DC: No it should include the 10mins

C: Was there any training with regard to record keeping for instance, how to record in records?

DC: No

C: And no guidelines in that respect were indicated?

DC: No

The coroner also asked her about how she knew whether staff understood care plans:

C: Alright, so with regard to ensuring that the staff understood the care plan, how was that dealt with?

DC: They signed sheets at the back of the support plan, they’d sign to say they’d read it and understood it.

C: And was there any assessment carried out to ensure they understood it as far as you could assess it? So, for instance is a document in Bundle 2 p1248 which is an assessment of competencies for providing support to a service user with a healthy, well balanced diet which is June 2021. Was there any assessment of staff competencies as at May 2018?

DC: No

C: So to ensure they understood the care plan they’d sign to say they’d read it and understood it?

DC: Uh hum

As the coroner summed it up when questioning Sarah Mann, the Director of Quality:

C: I’m concerned about training to complete the records properly, and as is required. The records themselves urgh, leave, um, leave it to people completing them to be quite vague if that’s what they choose to do.

One example related to Peter choking on 15 April. An event which one of the support workers, Siobhan Cator, described as traumatic for her, while the other said they had no memory of it.

C: p962 has initials SM at the bottom, is that your initials and handwriting?

SM: That is yeh

C: Alright, thank you. On that date were you with Peter when this happened? Were you supervising him?

SM: I don’t remember

C: Do you remember the incident? You made quite a detailed note about it.

SM: At the time I did, but no, I don’t

C asks again [didn’t catch]

SM: Yeh. I was given a transcript from the last inquest and read through those notes. Was an incident report made on that, that jogged my memory reading those, only through reading notes I don’t physically remember it as incident at the time.

At the time it was, it was dealt with and everything was fine, I’ve not kept it in my memory as an incident because everything was ok, does that make sense?

C: when it says at lunchtime Peter choked on a piece of chicken and cauliflower… staff removed excess food from his mouth and asked him to spit out anything in his mouth. Was that you who did that?

SM: Not that I can recall no

Of course the particularly concerning part of this is that the support worker with no memory, Suzanne Maunder, is the one who has written the notes and initialed them. Asked by the coroner about that this exchange took place:

C: Who normally writes these notes, the ‘have there been any concerns today’?

SM: Anybody, whoever was on shift. It’s pot luck, pick or mix, one staff member can be busy say taking someone down for personal care, and say can you start on the notes. Or we’d put all the folders on the table and pick one and start writing in it… would say how’s his day had been, what did he have for lunch and write it in, no specific person would write any specific notes, it was just however it came.

C: So a member of staff with Peter on 15 April saw him choke on chicken and cauliflower, it could be someone else who wrote those notes?

SM: Yeh could have been, they’d have been there and seen it and write it

C: So how would you know you were there if someone else could write the notes?

SM: Sorry I don’t understand what you mean

C: for instance on 21 May you were the only support worker in the room with Peter

SM: I’m not saying I was. It was a lounge dining room, the other member of staff could have been dealing with someone in the lounge area, it wasn’t a shut off area

C: So they were in another room?

SM: Could have been, I don’t remember, I don’t remember them sitting at the table, could have been over here or there

C: So they could have been in the lounge area. I understand there was a wall there?

SM: Yeh, an archway

C: So they wouldn’t have necessarily seen the incident but could write the notes?

SM: Yeh, they’d ask

C: So they’d rely on the other support worker telling them what happened and they’d write the notes?

SM: Yeh. Some staff go off at lunchtime and didn’t have time to write notes, other staff come in at lunchtime, they’d have to ask other staff what happened so they could write the notes.

C: And um, just before you left, as at December 2020, was that still the case? That support workers could perhaps write a note of the days events, when they hadn’t actually witnessed them?

SM: Yeh. There could be umpteen different things that happened in any particular day, staff could transfer from one building to another and have to write notes for building they weren’t in and would have to ask support worker who was there what happened. Does that make sense?

C: I understand what you’re saying, I’m not sure it actually makes sense, but I do understand what you’re saying

The coroner speaking for anyone following, it really doesn’t make any sense.

In addition to attempting to understand what was recorded, the coroner also tried to ascertain how decisions were made at the home with regard to staffing, and the duties of those staff working, particularly in relation to preparing food, and supervising meals.

The staffing rota was the responsibility of the Deputy Manager, Deborah Cuzner:

C: Who works out the rotas as to which members of staff are on?

DC: On that day?

C: Generally

DC: Trying to think back, if was myself or the manager. Well back then would be myself because the manager had left.

When asked how decisions were made about cooking, preparing food and supervising mealtimes, we were back to things not making sense again.

C: With regards to supervision, how did you ensure residents were supervised in compliance with their care plans?

DC: Unfortunately that was down to Team Leaders because I was more office based at that point

C: Did you consider as Deputy Manager that was part of your responsibility?

DC: Not trying to cover myself I’d only been a Deputy Manager for not too long, I was still learning my role.

C: Did you consider ensuring residents were appropriately supervised was part of your role?

DC: Back then I just assumed they were being supervised… Team Leader was part of their role to ensure day to day running of the floor was being done.

Gemma Peloe, the Team Leader, when questioned didn’t appear to be of the view it was her responsibility either, she felt staff just worked it out amongst themselves:

C: Working out who did what, was there a rota as to which staff were in on certain days and what their roles were?

GP: There was a rota as to what staff were in and what building they were in. I don’t recall if there were specific you’re doing this one person, don’t think it was that specific but couldn’t be sure.

C: What about who would be doing what? For instance, who would be supervising a particular resident, or who would be preparing and cooking meals, those sorts of jobs, who would organise those?

GP: It was kind of organised amongst themselves, amongst the staff, the meals were. We had I don’t know what they’re called picture cards, PECS pictures but bigger and service users that were able to choose, would point or verbally say what they wanted to eat, and then it was just amongst the staff they’d, the support staff would do it.

C: So just so I’m clear what your role was. You’d work out who would be taking service users out, if they required to be out?

GP: Yeh

C: There’d be a rota as to which staff were in, but with regards specific duties the staff would organise that themselves, have I understood that correctly?

GP: yes usually whoever got that service user up would be the one to support them throughout the day, because you can’t write notes about somebody else, so whoever wrote the notes that was that person.

When the coroner returned to this later in questioning we heard for the first time that apparently dangerous levels of record keeping was important to enable people to feel relaxed in their own home:

C: Going back to who did what. For instance, you’ve said if a member of staff got a resident up, they’d look after them for the rest of that day?

GP: Yeh, it was like, it wasn’t so regimented because it was more like a home from home, don’t know how to explain it. We wanted service users to feel comfortable and at ease, and not so regimented, you’re doing this this this at this time, it just flowed like when you’re relaxing at home.

The coroner picked the distribution of responsibilities up with Deborah Cuzner, the Deputy Manager, in her questioning. When asked about cooking and the preparation of food:

C: Generally then, how was it worked out who’d cook and prepare the food? We heard evidence from Ms Peloe but I want to understand what you’d understood.

DC: Again they’d arrange it between themselves on the day who was preparing food

C: And different people would be preparing different parts of meals?

DC: From what I’ve witnessed I’ve only known one person to be cooking a meal, from what I’ve seen, don’t know different people cooking different parts

C: So one person cook for residents in that bungalow?

DC: No they do share meals

C: So would there be one person cooking in one bungalow and shared out in each bungalow?

DC: No, they’d be one in one and one in the other side cooking different meals.

C: So cook different meals, and sometimes meals would be taken to residents in different bungalows?

DC: Yes

C: What about when someone was on a very specific diet as Mr Seaby was, soft moist and mashed, would it be either cook, either person in either bungalow could prepare the meal and that could then be taken over to Mr Seaby in the other bungalow?

DC: It could be, but 9 times out of 10 it would be in Woodcroft if that was the meal he wanted or was chosen.

Then we hear again the claim that they were so concerned that residents enjoyed a relaxed atmosphere and that nothing was regimental:

C: With regard to different roles a member of staff carried out, I’m not quite clear during evidence this morning how it was worked out who would do what. So 2 support workers and 1 team leader, I want to know how it was determined a member of staff would look after which resident, who would prepare food, who would do any 1-1 supervision required…. how was that determined?

DC: An informal way really (laughs) we tried to keep the home a home rather than institutionalised. When staff came in in morning would be team leader and staff on to discuss who was doing what that day. Through that day staff would decide between themselves to decide who was doing what (laughs). It would work, so it was a relaxed home environment, not regimental. Certain staff had better rapport with certain service users so they’d decide between themselves who was doing what.

C: Would that be recorded anywhere? We’ve got records from 21 May and I’m struggling to find who supervised Mr Seaby, if anybody, on that day. Something like that supervision in accordance with their care plan is there anything anywhere to say who would say was taking on that important role?

DC: No unfortunately not (laughs) the records don’t document very well

C: So it would be fair to say it didn’t always work

DC: No, but it did work on the day

C: The 21st of May?

DC: Yeh, they did it between themselves but the documentation unfortunately…

C: Well there’s no evidence I’ve seen that Mr Seaby was supervised is that fair to say?

DC: Yes

C: So it’s more than documentation.

When I’m in court and not tweeting I just make notes in real time, last week I made 280 pages of notes, comprising of 73,361 words, yet despite all the words, I’m still none the wiser as to how things are actually organised at The Oaks and Woodcroft, or the logic behind it. It all seems so careless.

My final post will address the Prevention of Future Death evidence and the three aspects that the coroner decided to make a report on, 5 years after Peter’s death, still concerns about the safety of others. For now I’ll end with what the coroner said about the relaxed approach to care:

I am concerned some 5 years after Mr Seaby’s death that I have heard evidence from a witness who is still at the care home that the informal approach to supervision and preparing work rotas is stated to work, when it clearly doesn’t.

There was reference more than once that an informal approach is the way to provide care in the care home, and whilst that is commendable in providing a caring environment, this must be balanced with the need for structure and rules and protocols which must be followed by all those involved in the care of vulnerable residents.

Those requirements are there for a purpose and an informal approach has no place in a care home.