Care Home Provider Acknowledges Outdated Staff Training After Resident’s Death, Inquest Hears

A provider of care home services, where a 29-year-old resident passed away, has acknowledged that some staff instruction was “slightly out-of-date,” an inquest has revealed. Holly Goodchild suffered a fatal collapse and died on 29 March last year at Cygnet House near Great Yarmouth, a residential facility catering to individuals with learning disabilities, autism, and mental health requirements. Norfolk Coroners’ Court was informed that the deficiency in training at the facility was attributed to “not having enough of our own staff.” Michelle Smith, an operational manager for Crystal Care, the company operating the home in Belton, stated that staff recruitment presented an “absolute problem.” Ms Goodchild’s medical cause of death was identified as positional asphyxia, epilepsy, morbid obesity, and left ventricular hypertrophy. The court had previously heard that Ms Goodchild did not receive epilepsy medication on the night of her death. Ms Smith, whose role involved supporting Crystal Care’s homes and managers with systems, processes, and compliance, informed the court that “there was some training that was slightly out of date due to not having enough of our own staff.” When questioned regarding the error concerning the epilepsy medication, she explained that the Care Quality Commission (CQC) had told the home “we were over reporting our medication errors.” The company reported medical errors to the NHS inspectorate solely if a GP or the NHS 111 phone service indicated that the error was likely to cause harm, she said. Senior coroner Jacqueline Lake was also informed that Ms Goodchild’s mental capacity form had been filled out incorrectly. When queried whether this indicated a weakness among the staff, Ms Smith responded that there were “sufficient numbers [of staff] but not always strength.” The court had been informed earlier that she was not promptly given first aid because staff believed she was “attention seeking.” Ms Smith further stated to the court that the initial response to Ms Goodchild’s collapse “should have been to call 999.” Ms Lake inquired if the home possessed mobile phones. Jennifer Grego, Crystal Care’s co-director and registered provider, confirmed its availability but remarked, “why they didn’t use it, I’m unable to say.” Every resident at the facility has learning disabilities, with some also presenting conditions like epilepsy or mental health conditions, she stated. However, she informed the court that staff were not “recording [data relating to behaviours of clients] at the level they needed to record.” She further stated that the company was “definitely addressing all the issues [raised in the inquest].” The inquest is scheduled to conclude this week.