‘Lessons learned’ after dementia patient found dead in pyjamas outside care home

WALKED OUTSIDE ... An elderly man was found dead in his pyjamas outside Stapleton House care home, in Jarrow. South Tyneside coroner Terence Carney has held an inquest into the death.
WALKED OUTSIDE ... An elderly man was found dead in his pyjamas outside Stapleton House care home, in Jarrow. South Tyneside coroner Terence Carney has held an inquest into the death.

A DEMENTIA-stricken OAP who was found dead in his pyjamas outside a South Tyneside care home should never have been able to walk out undetected, a coroner has said.

Care home bosses apologised and said lessons had been learned following the death of John Cooke, 83, who had receiving end-of-life care at Stapleton House, in Borough Road, Jarrow.

I am still of a view that he shouldn’t have been out there in the first place and that is a matter of some measure of concern.

Terence Carney, South Tyneside coroner

An inquest, led by South Tyneside coroner Terence Carney, heard that the father-of-one, who had dementia, was found lying on the ground outside the home wearing just his pyjamas and slippers by a passer-by on May 28 last year.

Mr Cooke, who had lung cancer, enjoyed wandering around the home – which was then run by Four Seasons Health Care but has since been sold – and would often go for walks outside.

But it is believed he left the care home through an emergency exit, that should have been alarmed, without any of the four staff on duty noticing.

After the inquest, a spokesman for Four Seasons Health Care said they were sorry Mr Cooke had not been risk assessed for his walks.

Mr Carney said: “John could have died at any time and one of the complexities, but simplicities, of this case is that had he died in his bed no one would have been surprised.

“The matter of concern to me is that he didn’t die in his bed or in the home, he had somehow got out of the home and collapsed in the street.”

“I am still of a view that he shouldn’t have been out there in the first place, and that is a matter of some measure of concern.”

Rosemary Brown was cycling from her son’s house in Hebburn to her home in Low Simonside, Jarrow, when she saw Mr Cooke lying in the lane behind Stapleton House and called for an ambulance.

She said: “I saw a man lying sort of in the gutter and I had to look twice because I didn’t believe what I saw.

“He was lying there in his pyjamas and slippers.”

British Red Cross service manager, Charles Jevan, who responded to the call with a colleague, said it had been a cold and wet night.

He also asked staff if Mr Cooke had a do not attempt resuscitation (DNAR) order in place and asked to see paperwork when he was told that was the case.

He checked Mr Cooke’s vital signs but found none and after being shown the DNAR, said there was nothing he could do.

Dr Clive Bloxham, the pathologist who carried out the post mortem examination on Mr Cooke, gave his cause of death as metastatic non small cell carcinoma of the lung, meaning the disease had spread throughout his body.

He said the death was contributed to by dementia, chronic obstructive pulmonary disease, a condition of the lungs, and left ventricular hypertrophy, an enlarged heart.

He also said he believed the outcome would have been the same had Mr Cooke been inside the home, and that the death would have been sudden.

Mr Cooke’s son Michael said his father, originally from Biddick Hall, South Shields, had been diagnosed with cancer in 2013 and had gone into the home because he needed 24-hour care.

He also said that on May 26, last year, a doctor said his father was in the final days of his life.

Staff nurse, Janiz De Juan, who was on nightshift when Mr Cooke died, said she had seen him in the hallway shortly before a member of the public came to say someone was outside the care home.

When asked by Mr Carney about the procedures of locking up the home, she said: “We lock the front door and staff normally do checks while they’re doing the rounds.”

Amanda Cunningham, North East managing director for Four Seasons, said that although the company no longer runs the care home, they had learned from their errors and made changes to the way care plans are kept. Mr Carney said he was satisfied that lessons had been learned from the death.

He said: “I’m satisfied in this case that whilst I can and should record John Cooke’s death as one of natural causes, I can and should record that that death was in part contributed to by a failure to appreciate the imminent nature and expectation of that death.”

n Finding: Natural causes in part contributed to by a failure to appreciate the imminent nature and expectation of that death.

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Case review after patient’s death

HEALTH bosses carried out a case review after Mr Cooke’s death, the inquest heard.

David Jopling, of the quality and regulated services department, part of the commissioning team at South Tyneside Council, said he found no care plans relating to Mr Cooke’s need for oxygen and his breathing problems, and no notes reflecting his changes in agitation and confusion, and how staff had managed to calm him down.

Mr Jopling said there were also no care plans in relation to his lung cancer or the palliative care surrounding his final days, and no risk assessment regarding his tendency to go for walks outside the home.

He also said there was no policy or procedure in place around securing the building on an evening.

Mr Jopling added: “The staff had a good knowledge of Mr Cooke and his needs but there were no records in his care plans. What our commissioning service is looking for is accurate records and that was lacking.”

After the inquest, a spokesman for Four Seasons Health Care said: “Mr Cooke’s death was a tragic loss and our thoughts and sympathies go out to his family at this time.

“Mr Cooke was receiving end-of-life care at the home. He had been in the habit of occasionally going out for a short walk in the evenings.

“However, on one of these walks a passer-by saw that he had collapsed and alerted the home. An ambulance was called. Two ambulances attended and paramedics recorded his death at the scene.

“Although Mr Cooke was deemed mobile, we are sorry that he had not been risk assessed for his walks. As a result of this incident we made changes to improve risk management and service procedures including further training of staff.”