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Care home pensioner ‘neglected’ so much he was ‘dying’ on admission to hospital

An inquest has heard how an 82-year-old man who had Parkinson’s disease was “neglected” so bad in an understaffed care home that he was “dying” when he was admitted to hospital.

Murray Hyslop, was isolating following an outbreak of Covid where he had been one of 45 residents and 44 staff who had tested positive.

Pensioners were restricted to staying in their rooms, where care was limited but delivered as well as food and drink.

However, this week at an inquest into the death of Mr Hyslop, it was heard how his condition had significantly deteriorated in the days leading up to his admission to hospital on Christmas Eve last year.

The coroner issued a prevention of future deaths report to Willow Care Home following the inquest

By December 18, 2020, Mr Hyslop’s poor health had been demonstrated by him drinking less fluid.

Family-oreinted Hylop’s presentation was witnessed by his son, Andrew Hyslop, on December 20, and as evidenced by his need of a hoist to get into bed, according to a report in Nottingham Live.

The inquest heard it had been obvious to Andrew Hyslop how unwell his father was and so, as a result of his persistence, Mr Hyslop received a visit from the out-of-hours GP that night, who recommended admission to King’s Mill Hospital.

Assistant coroner Gordon Clow said: “There was significant confusion in the approach of Willow Tree House, in Mansfield, to that aspect of the chronology. On the one hand, it seemed to be being suggested within their evidence that Mr Hyslop was not in need of medical attention.

“Reference was made to a transporting staff member (who was not instructed to clinically assess patients) suggesting that observations had been taken of Mr Hyslop and that the results were “better than his”.

“This was at a time when Mr Hyslop had been assessed as being acutely unwell by the visiting GP and shortly prior to the assessment of him on admission to hospital when it was clear that not only was Mr Hyslop unwell but that he was, in fact, dying”.

In the early hours of Christmas Eve, the frail, dehydrated and emaciated pensioner was admitted to King’s Mill.

On arrival, Mr Hyslop was noted to be unresponsive. He had an “acute kidney injury” – where the kidneys suddenly stop working properly.

Given that he had been in a care home, concerns arose as to whether he had been appropriately cared for prior to his admission and a referral was made by hospital staff to the Local Authority’s safeguarding team.

Andrew Hyslop, who attended the inquest every day, made a complaint on his father’s behalf regarding the care afforded to his dad, who had lived in Mansfield Woodhouse before going into the home.

An investigation was carried out by the Local Authority into the events leading up to Mr Hyslop’s admission and the Local Authority made a finding that the allegation of neglect was fully substantiated.

The Care Quality Commission carried out an inspection on the back of complaints from Andrew Hyslop and other persons with relatives at Willow Tree House and the home was rated as “inadequate” following an inspection of the home in January 2021.

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A subsequent inspection took place in June 2021 and this resulted in an overall rating of “requires improvement” but with safety still rated as “inadequate”, the inquest heard.

At the end of the inquest, Mr Clow said: “I find that Mr Hyslop may have survived had treatment been sought at an earlier stage, but I cannot say, on balance of probabilities, that he would have survived”.

Mr Hyslop senior died from pneumonia (1a) undiagnosed Ischaemic heart disease (1b) on January 16, 2021.

Mr Clow highighted concerns over: Prevention of pressure damage “there was a lack of appreciation of the need to consider Mr Hyslop’s extreme vulnerability to pressure damage when he was very unwell, dehydrated, malnourished and largely immobile”.

A second concern was “Identifying a resident in need of medical attention”, with Mr Clow saying, “some of the difficulties in Mr Hyslop’s care were exacerbated by the outbreak of Covid-19, but there was no evidence of any expectation upon any members of staff to consider a broader view of Mr Hyslop’s presentation than how he was on a particular day”.

The third was “learning from adverse events,” where Mr Clow said the culture within senior staff of obfuscation and denial when issues regarding care are raised was of significant concern to me as it is hard to have confidence that, as they said to me, “lessons will be learned”.

And Mr Clow issued a prevention of future deaths report to My The Orchards Ltd, the company Willow Tree House is part of.

He told the hearing: “I have to consider whether, having developed concerns upon hearing the evidence about risks of future deaths, the submissions on behalf of Willow Tree House have sufficiently dealt with such concerns such that I no longer have an evidence-based concern that there may be future deaths.

“My concerns remain and, given the vulnerability of the residents within care homes, I cannot say that the issues do not risk future deaths. I am under a duty, therefore, to issue a prevention of future deaths report to My The Orchards Ltd. This will follow within the coming 14 days and will require a response in the usual time frame”.

Andrew Hyslop, a retired police Inspector for Nottinghamshire Police, had put questions to witnesses at the inquest and was “elated” at its conclusion, where a narrative verdict was recorded, and “it has been acknowledge my dad was not properly looked after”.




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