A HEREFORDSHIRE care home has spoken out after a resident died after delays in medical treatment.

An investigation was opened into the death of John Patrick MacGregor in April 2023 the Prevention of Future Deaths report submitted by Herefordshire coroner Mark Bricknell said, with an inquest on February 28 recording a narrative conclusion.

Mr MacGregor had been admitted to hospital with chest pain and shortness of breath after a fall at Credenhill Court Rest Home the report said, where he was found to have a number of injuries including fractures.

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But, the report said, Mr MacGregor became significantly more unwell, despite treatment, and the decision was made to start him on the end-of-life pathway.

It also said that while the fall had happened on April 2, "substantive medical intervention" did not take place until April 13, when he was "profoundly unwell".

Mr Bricknell said inquest evidence had revealed matters giving rise to concern, including the quality of residents' care documentation and its completion, and procedures for escalation and subsequent medical intervention following a fall.

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"In my opinion there is a risk that future deaths will occur unless action is taken," the coroner said in the report, which has been sent to the care home and the chief coroner.

In a response sent to the coroner on April 24, a spokesperson for the home said it no longer facilitates respite residents.

Senior care staff are now being supported through weekly discussions to ensure they are confident in documenting resident needs, while the falls protocol has been reviewed.

"We believe it is effective and each fall is taken on its own merit," the spokesperson said.

Concerns are taken to appropriate health professionals, and any resident who does fall is monitored for 24 to 48 hours, regardless of the severity.

Other measures being taken include a review of the medication processes for residents taking blood thinners, with the spokesperson saying no concerns were found, while a daily written handover sheet has now been introduced for care staff to complete.