Care home urged to review training after Walsall grandmother dies
A care home operator has been urged to review "do not resuscitate" training after a grandmother died amid staff confusion.
Diabetic and dementia sufferer Tripta Bhanot, died aged 86, on May 9 last year after being placed at Anson Court Residential Home, in Harden Road, Walsall, for respite care.
The inquest held on August 4 this year concluded that the cause of death was "unascertained".
Now a prevention of future deaths report by Black Country senior coroner Zafar Siddique has called for improvements in training, communication and guidance relating to escalation of emergency situations.
His report stated: "She was found on the floor of her bedroom on May 5 and had sustained bruising to her face and shoulder.
"On May 9 she was again found on the floor at around 4.45am and no apparent injuries were found.
"She was placed back into bed by care staff. Later that morning at around 9am she was again found on the floor by care staff.
"Her condition declined rapidly and and there was confusion amongst staff whether a “Do not attempt to resuscitate (DNAR)” order was in place.
"During the course of the inquest the evidence revealed matters giving rise to concern.
"In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you.
"The matters of concern are as follows.
"Evidence emerged during the inquest that there was a lack of clarity and understanding by care staff in the requirements for escalation to emergency services when a patient/resident becomes acutely unwell.
"There was lack of clarity and understanding by care staff of the role of the enhanced care and quality team and circumstances for referral to them. There was evidence of poor procedures in place in identifying the DNAR status of residents.
"Action should be taken. In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. The care home owners may wish to consider reviewing their training and guidance on DNAR and escalation to emergency services.
"The hospital trust may wish to consider reviewing their guidance and communication with care homes in relation to the role of the enhanced care and quality team."
Anson Court's operator Manor Court Healthcare Ltd and Walsall NHS Healthcare Trust have until November 16 to respond to Mr Siddique's report.
Copies have also been sent to Mrs Bhanot's family and the Chief Coroner.
Mrs Bhanot and her husband Hari, 83, were prominent members of the town's Hindu community and died within 21 days of each other.
They had lived in Sheridan Street, Pleck, but were originally from Punjab, in India, and met through an arranged marriage.
