Frail 95-year-old died of hypothermia after boilers failed at carehome

Frail 95-year-old woman died of hypothermia and pneumonia after condemned 50-year-old boilers failed at ‘inadequate’ care home

  • Doreen Osborne was found in a ‘severely hypothermic state’ in Norfolk home
  • Paramedics rushed Foreen to hospital after temperature was 9C below normal
  • She was left without vital medicine after staff sent prescription to wrong chemist

A frail 95-year-old woman died of hypothermia and pneumonia after both 50-year-old boilers failed at her ‘inadequate’ care home.

Doreen Osborne was found with her temperature 9C below normal after her she had been left without central heating and vital medicine for three weeks.

Emergency services rushed the pensioner to hospital after finding her in ‘a severely hypothermic state’ at the Pineheath care home in High Kelling, near Holt, Norfolk as temperatures plunged below freezing.

The report by the Norfolk Safeguarding Adults Board revealed that the two boilers dated back to the 1960s and had not been replaced since one failed two years ago, despite being condemned in 2013.

Doreen Osborne, 95, was found with her temperature 9C below normal after her home had been without central heating and vital medicine for weeks

Staff at the privately-run home had reportedly been using temporary heaters and water boilers and had resorted to carrying jugs of hot water from the kitchen to wash residents.

Mrs Osborne was diagnosed as having a chest infection and prescribed antibiotics by a GP who visited her in November 2016.

But staff at the home faxed her prescription to the wrong chemist which meant the drugs were never delivered and her condition rapidly deteriorated.

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Staff dialled 999 after becoming concerned about Mrs Osborne at 5.35am the following morning on November 9. 

Paramedics found her severely hypothermic with a body temperature of 27.5C, around 9C below normal. They also noted that the home’s environment was ‘extremely cold’, the report said.

A second ambulance crew was requested to carry out welfare checks on other residents at the home after paramedics were so concerned. 

Emergency services rushed Mrs Osborne to hospital after finding her in ‘a severely hypothermic state’ as temperatures plunged below freezing

Mrs Osborne, who used a wheelchair, was taken by ambulance to the Norfolk and Norwich University Hospital where she died the same afternoon.

The care home owner and manager were interviewed on suspicion of manslaughter by gross neglect, but the Crown Prosecution Service’s complex case unit decided to take no action against them.

The report revealed that the Care Quality Commission had requested the police files on the case and was still considering a possible prosecution under the Health and Social Care Act.

Mrs Osborne’s daughter Susan Sampson, 73, of High Kelling, said her mother used to work as a packer at a Sainsubry’s store in Wimbledon, south London, before moving to Norfolk.

She said: ‘I blame the care home for her death. She was without proper heating for three weeks. The boilers were very old and they should have been replaced years ago.

‘My mother told me that the boilers were broken and she was complaining that she was cold all the time. She did not have a shower or get her hair washed for the whole three weeks.

Former Pineheath care home in High Kelling, near Holt, Norfolk. Staff had reportedly resorted to carrying jugs of hot water from the kitchen to wash residents

‘She was depressed about it, and would say: “I am freezing. I don’t know what to do with myself”.

‘I kept on going into the office to ask what was happening and they kept saying that they were going to get it fixed. Then there were excuses about parts being missing.

‘They said they had heaters, but I only saw a small portable blower on the day she died.

‘The window in her room had its catch broken by a resident with dementia about six months previously. It was repaired but it never shut properly after that. There was a one inch gap where it was open at the bottom so there was a constant draught.’

Mrs Sampson said her mother who was divorced had been paying £500 a week to live at Pineheath, using money from the sale of her former home in Wimbledon south London.

She added: ‘I asked her numerous times if she wanted to moved, but she said that she had friends there and liked the people. But it began to change when they lost a lot of the staff and had to use more agency staff.’ 

The care home was run by Essex based company Diamond Care (UK) before it closed. 

The report did not name the care home or Mrs Osborne, referring to her only as Ms E.

But her identity was revealed by records which showed an inquest into her death was held at Norfolk coroner’s court in August last year.

Norfolk’s senior coroner Jacqueline Lake recorded a narrative conclusion, saying she had died of bronchopneumonia and hypothermia.

Mrs Lake added: ‘The evidence does not reveal which developed first or to what extent the two issues noted above contributed to Mrs Osborne’s death.’

The coroner also noted that boilers at the home had broken and Mrs Osborne had gone without antibiotics. 

The home, which was said to be in an ‘old poorly-insulated building’ with high ceilings and large rooms, was closed down by its owner in May 2017 after Care Quality Commission inspections rated it as inadequate two months earlier.    

Problems identified included draughty windows which did not close properly, inadequate safety in a lift and ongoing concerns about legionella. 

Staff had claimed that temporary heaters were being left on overnight and checks carried out on rooms every 15 minutes to ensure they were warm enough, the report noted. 

One resident was said to be so cold that they had to be wrapped in a blanket so that a GP could extract a blood sample. 

The legionella bug was found in three rooms and new hot water tanks were installed. 

The Norfolk and Norwich University Hospital expressed ‘grave concern’ to the county council about the residents of the home on December 12, amid fears about infection control and legionella. 

The CQC did not contact the care home, or anybody else for three days after a family member called with concerns on October 28, 2016.

Norfolk County Council’s enquiry desk had learnt of the issue from a relative on October 31, but did not raise it as a safeguarding concern and only emailed adult social care’s quality assurance team the following day.

Neither the council or the CQC were said to have checked the logs that staff had been keeping of room temperatures 

Joan Maughan, chair of the Norfolk Safeguarding Adult Board, said: ‘It is clear from this review that there were failures in health and safety standards at the care home where she was living.

‘Safeguarding Adult Reviews take place so that we can all learn lessons from what has happened and look at what changes might need to be made to prevent tragedies from happening in the future.

‘It is therefore particularly concerning that the owner of the care home would not engage with this review.

‘Providing adequate hot water and heating should be among the minimum expectations in a home looking after older and vulnerable residents and it is clear that standards fell well short of what we as a board would expect. 

‘However, it important to emphasise that there was some very good practice in this case, particularly from the paramedics who visited the home on the day Ms E died.

‘Their quick actions identified the risk to Ms E and others and ensured other residents received the healthcare they needed. 

James Bullion, executive director of Norfolk County Council adult social services, said: ‘The failure of this care home to adequately care for its residents and keep them safe is particularly distressing.

‘We accept the recommendations of this safeguarding adult review and also share the board’s concerns that the owner of the home would not take part in this review. 

A spokeswoman for the CQC said: ‘CQC was part of the review regarding the death of a lady who had been receiving care in Norfolk and we are aware of the outcome published by Norfolk Safeguarding Adults Board.

‘We have examined what happened in this case and are working with the local authority to ensure that any lessons from the review are learned. Our sympathies are with the family of the lady who died.’ 

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