South Lakes care home addresses fatality after nurse 'forgot' training

James Reginald Capstick, who was 83, suffered 10 fractured ribs after being given CPR when he was not in cardiac arrest.

Dr Nicholas Shaw, assistant coroner for Cumbria, said he was concerned about the risk of future deaths at Westmorland Court home in Arnside

Dr Shaw said: "The continuation of chest compressions by a registered nurse in the face of clear indications that her patient was not in cardiac arrest but alive was a gross failure in basic care and can be classed as neglect."

Care home bosses said it had 'taken valuable lessons' after his death.

Now the coroner has issued a prevention of future deaths report highlighting concerns into the circumstances of the death.

The nurse said in her statement she 'forgot her' basic training and had never attempted CPR before.

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Dr Shaw determined the injuries contributed to his death.

Mr Capstick had suffered from Type 1 Diabetes and Autonomic Dysfunction and needed to be nursed laying down in bed.

He often had 'absent' periods where he was unresponsive.

According to Dr Shaw's 'future deaths' report, he became unresponsive in December 2021 after several episodes and the home made a 999 call.

The coroner said there was 'great confusion' between the call handler and the nurse, who is not named in the report.

Her inconsistent responses were documented in transcripts.

He added: "This confusion led to over 20 minutes of chest compressions being continued on Reg despite clear signs of life - basic checks to confirm this were not carried out."

Mr Capstick was then admitted to hospital with a chest injury and the ambulance crew raised a safeguarding referral.  

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Dr Shaw continued: "Reg returned to Westmorland Court early in 2022, friends who visited were very concerned about the quality of care given and made a second safeguarding referral.

"I heard at the inquest that both these referrals were closed by social services."

The ambulance crew admitting him to Royal Lancaster Infirmary were also very concerned by his appearance, it was said.

Apart from illness, he was said to be dirty, unkempt, emaciated and dehydrated with a neglected dry, caked mouth, said Dr Shaw.

A third referral was then made.

It was during an inquest earlier this year that Dr Shaw determined that the combination of the 'massive chest injury' and pneumonia led to his death on October 1, 2022.

The home has 56 days to respond to the report and outline any action it is taking.

A spokesperson for the care home said: "In 2021, a regrettable incident took place. The care home extends its sincere apologies for this event and the distress it caused to Mr. Capstick's friends.

"We acknowledge that errors were made during that period. We have taken valuable lessons from this incident and have since improved our practices to prevent similar occurrences in the future."

During the inquest, Dr Shaw said he had been told the nurse was 'stepped down' from duties for a short while and returned to work after further training.

He questioned if a referral to the regulators The Nursing and Midwifery Council, which has also received his report, had been closed,

Lesley Maslen, Executive Director of Professional Regulation at the Nursing and Midwifery Council (NMC), said: "We are reviewing the Prevention of Future Deaths Report, and we will provide a response to the coroner, including details of whether any appropriate action is needed."

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Westmorland and Furness Council is responsible for social services in the south of the county. 

A spokesperson for Westmorland and Furness Council said: "The council was made aware of the incident at the time and the outcome of the recent Coroner’s report.

"Working with relevant partners, we continue to pro-actively work with the care home. Our thoughts are with the family of Mr Capstick."