Prevention of Future Deaths report: Geoffrey Whatling (6 November 2023)

Summary

While at Amberley Hall Care Home for rehabilitation, Geoffrey Whatling’s family had raised concerns that he was unwell. He was scored as a 7 on the National Early Warning Score (NEWS2) system on the 8 April 2023. Such a score requires a 999 call to be made, however instead a 111 call was made. The 111 call taker was not made aware of his NEWS2 score.

Further observations were carried out on 9 April 2023 (NEWS2 score 6), and 07.00 (NEWS2 score 5) and again on 10 April 2023 at 12.13 (NEWS2 score 9/10), when emergency services were called and Mr Whatling was admitted to Queen Elizabeth Hospital. Despite treatment his condition continued to deteriorate and he died on 26 April 2023.

Content

The Coroner in their report raises a number of matters of concern:

• Mr Whatling was not eating and drinking very much. A food and fluid chart was not fully completed.
• Emergency services were not called on 8 April 2023 when Mr Whatling scored NEWS2 7 as required.
• The evidence so far revealed is that 111 call taker was not made aware Mr Whatling had scored NEWS2 7.
• Mr Whatling’s observations were not taken hourly as required.
• Some of Mr Whatling’s observations were recorded on a piece of paper and were not logged in his Care Records.
• The Manager only became aware of gaps in the records following concerns raised by the family.
• There is no evidence that any action has been taken following Mr Whatling’s death.