A father has described legal support for bereaved parents as “pathetic”, saying he cannot bring a civil case over his disabled daughter’s death because he would risk losing his home.
Keith Bailey’s daughter Joanna, from Collier Row in Havering, died in a Norfolk care home in April 2018.
Last November, he and his wife Jean, both in their 70s, sat through a five-day inquest which revealed numerous failings in Joanna’s treatment at Jeesal Cawston Park. They included:
- Insufficient staffing
- Failure to carry out proper observations on Joanna
- Failure to ensure she was wearing a potentially life-saving breathing mask
- The team leader’s first aid training was expired
- Nobody attempted CPR
Since the 36-year old's death, more serious problems have been uncovered at the home, including repeated instances of staff sleeping on the job, which inspectors said had resulted in harm to patients.
But Keith cannot claim legal aid for a civil action against Jeesal, which he feels has not been properly held to account.
“I feel very let down and disappointed in the whole system,” he said. “I think the legal system is pathetic, really.”
'A happy child'
Joanna was diagnosed with learning difficulties at age three and held back at primary school.
But, said Keith and Jean, she was “a very jovial and happy child”. She loved music, discos and karaoke.
At around 18, she started having seizures. Neurologists discovered she had epilepsy and sleep apnoea. They told her to start using a Continuous Positive Airway Pressure (CPAP) machine at night.
She responded “marvellously” and “immediately ceased” having seizures in her sleep, they said.
But persistent daytime seizures, alongside her learning difficulties, made it impossible for her to work. Craving independence, she moved to a Romford care home, The Grange.
In her mid-20s, her mental health deteriorated. She moved to Goodmayes Hospital, then a care home, then a private hospital.
In October 2016, Keith and Jean were told the nearest facility specialised enough to look after Joanna’s complex needs was the Jeesal group’s Cawston Park facility, near Aylsham.
They were unhappy about the distance, but agreed to the move.
Visits to Norfolk
Keith and Jean visited Joanna every other weekend.
She complained that staff shortages prevented her from participating in some activities, as there were insufficient carers to accompany her, but her parents said they were not alerted to any other problems.
On April 27, 2018, they visited Cawston Park for a meeting. They were told Joanna was “doing well” and might soon be able to move much closer to home.
They noticed Joanna was stuttering. Before leaving, they warned staff that this usually meant she was about to have a major seizure.
“We asked them to keep an eye on her,” said Keith.
The couple stayed at a hotel for the night. When Keith woke up at around 7am and switched on his phone, he found several missed calls from Cawston Park.
“I rang the doctor and he just said, ‘I’m awfully sorry to tell you that your daughter’s passed away’,” he recalled. “To which we both burst into tears and just couldn’t believe it.
“We zoomed off up to the hospital. He met us and said that they had done all they could on the night.”
This, an inquest heard in November 2020, was not true.
What happened that night?
Agency support worker Stella Egbuchelem was on duty on the night of Joanna’s death. She told the inquest that when the day shift handed over to the night shift, they learned there were was a staff shortage.
She said a nurse also made a comment about Joanna, saying she had suffered a seizure that day and was “playing up”, so staff “should not mind her”.
The nurse who allegedly made this comment was not called to testify at the inquest, but an email was read to the jury in which she denied saying it.
Support worker Dan Turcu testified that despite Joanna’s seizure earlier that evening: “She was just on general observations. Nobody told us to have a special watch for her.”
Entries were recorded on the Cawston Park computer system at 2.45am and 3.03am, saying a staff member had checked Joanna and seen “breathing and movement".
But CCTV footage proved Joanna was found unresponsive shortly after 3am, and nobody had checked on her for at least 75 minutes before that.
She was supposed to be checked every 30 minutes.
At the inquest, Sarah Wigger, who was supposed to carry out the observations, said computer entries were sometimes logged with incorrect times if the equipment lost internet connection.
She accepted that during the observations she did carry out that night, she did not “visually” check on Joanna.
“I walked past and I could hear her snoring,” she testified.
Asked why records said movement had been observed, she said the computer system at the time had autocompleted sentences for staff.
“It was inaccurate,” said Ms Wigger.
The nurse in charge that night, Annita Nyabunze, said that at the time, they had not properly monitored observations and had relied on staff to do as was expected of them.
Shortly after 3am, Mr Turcu discovered Joanna was not breathing, so ran to get Ms Nyabunze.
She attended Joanna’s room, left and then returned with equipment to check her blood pressure and oxygen levels.
But, witnesses testified, nobody fetched any resuscitation equipment and nobody attempted to perform CPR.
Ms Egbuchelem said she could not do it as she was not allowed to leave her own patient. Her colleague said the same.
Ms Wigger said she was “frozen”. Mr Turcu described himself as being “in a panic attack or a shock”.
The inquest heard Mr Turcu’s first aid training was expired at the time. He said he had not realised.
No CPR
Kyle Velardo, from the East of England Ambulance Service, wrote in a statement that when 999 was dialled: “We were informed that CPR was in progress”.
But when he and a colleague arrived at 3.43am, he wrote: “There was no CPR being undertaken by staff and no resuscitation equipment or [defibrillator] present.”
Joanna was still on her bed, laying on her side.
Paramedics attempted CPR for roughly 20 minutes, but she was pronounced dead at 4.09am.
When they checked Joanna’s care records, they saw she was supposed to receive one-to-one observation and should have been using a CPAP machine.
Police were called, which is normal for a sudden death.
PC Pauline Gray wrote in her statement: “The ambulance staff told us they had concerns because there did not appear to be one-to-one care and although her [CPAP] device was on a bedside table, she was not wearing it. They were told she had refused to wear it.”
PC Gray wrote that she found the lack of CPR efforts by staff, and their explanations for it, “very strange”.
Machine not used for three months
After Joanna’s death, her CPAP machine was returned to her parents.
“I said, ‘This doesn’t look like it’s been used’,” said Keith. “With use, the mask gets distorted and looks a bit dirty and squashed. But it looked in perfect condition.”
He had the machine analysed and discovered that in the last 209 nights of Joanna’s life, the machine had only been used 29 times. By the time she died, it had not been used for more than three months.
“The doctors were astounded because they used to say Joanna was their star pupil,” said Keith.
The inquest heard that a few months before she moved to Cawston Park, Joanna’s machine had been analysed, revealing that she had used it on 82 out of the last 85 nights.
“That's an impressive amount,” Professor Matthew Walker, a neurologist who treated Joanna, told jurors. “She was using it more consistently than most people.”
Professor Walker testified that Joanna was not coordinated enough to affix the mask by herself and required help to do so.
Yet the inquest was told that the requirement for her to use the machine was never put in her care and treatment plan at Cawston Park.
“On the night that she died, whose job was it to encourage Joanna to use her CPAP machine?” Mr Turcu was asked.
He said he had believed Joanna had the “capacity” to make her own decisions regarding her welfare.
“Us as staff, we never forced her to put the machine on,” he said.
He did not know whether anybody had discussed with Joanna the need for her to wear her mask that night.
Professor Walker told jurors that the machine might have prevented Joanna’s fatal seizure.
11 concerns
Coroner Yvonne Blake told jurors there was insufficient evidence that the failures in Joanna's care had directly caused her death, leaving no choice but to rule she had died of natural causes.
But when they returned their verdict, they attached a list of 11 concerns about Cawston Park.
They included quality of training, staff shortages, governance, ineffective communication with Joanna’s family and a “fear of blame culture” preventing staff from providing adequate care in an emergency.
INQUEST, a charity which supports the victims of state-related deaths, said Joanna had been “let down by a damning series of failures in her care”.
“The whole thing is a shambles,” said Keith. “And the more you hear about that hospital, the more of a shambles it seems to be.”
He was referring to a series of recent findings by the Care Quality Commission (CQC), the independent regulator for health and social care services.
The Inspectors
Seven months after Joanna’s death, in November 2018, CQC inspectors visited Jeesal Cawston Park.
“The provider did not deploy sufficient numbers of staff to safely maintain patient observation levels,” they wrote in a report.
When inspectors returned in June and July 2019, they found the problem persisted.
They also wrote that they had received complaints of staff sleeping on the job.
Another problem highlighted by their report was that patients with sleep apnoea were still not using their CPAP machines – but no assessments had been done as to whether they had capacity to make safe decisions about their welfare.
The inspectors rated the facility “inadequate” and placed it in special measures.
In May 2020, the CQC returned to Cawston Park after being informed of two “patient incidents”, one of which had involved observations not being completed safely.
“We reviewed CCTV footage of the incidents, clinical notes and documentation relating to the incidents of concern. We also viewed a random selection of CCTV footage from recent incidents that the service had recorded on their incident log,” inspectors said.
“The CCTV footage confirmed that staff had not completed patient observations safely as they had fallen asleep.”
Cover-up culture
In August 2020, the CQC returned once again.
“The inspection team found further incidents where patients were placed at risk of harm due to observations not being completed properly,” said its report.
"At the last three inspections, we had reported on the high number of incidents that had occurred where patients had caused harm to themselves, or were exposed to harm, due to observations not being completed correctly.”
Despite these repeated warnings, inspectors wrote, “patients were still being put at risk.”
The inspectors found further evidence of night shift staff sleeping on the job.
“We reviewed seven pieces of randomly selected CCTV footage and found that on five of the occasions a member of staff was asleep when they were meant to be carrying out their duties,” the report continued.
“When some staff commenced their enhanced observation duties, we saw that they had brought with them a cushion or pillow and made themselves comfortable on the chairs before falling asleep.
“We saw evidence of staff moving chairs, or sitting in unusual places such as a kitchen worktop, which positioned them out of sight of the CCTV cameras.
“This demonstrated there was intent behind their actions and evidence of a culture which covered up these practices amongst night staff.”
Despite these findings, the CQC boosted Cawston Park's overall rating out from "inadequate" to "requires improvement" – but maintained its “inadequate” rating for safety and kept it in special measures.
What now?
“We are full of grief still,” said Keith. “And anger. My personal view is that Cawston Park should have been shut down a long time ago."
The CQC said it had intended to “cancel the registration of this service,” but that Jeesal had appealed. When inspectors returned after the appeal, they observed some “improvements”.
CQC enforcement action has reduced Cawston Park from 57 patients to 12, “to ensure safer care”.
“The service continues to be closely monitored and we will not hesitate to take further enforcement action if necessary,” a CQC spokesperson added.
Keith and Jean wanted to take civil action against Jeesal, but decided they could not do so after learning that if they lost, they would be liable for all of the company’s legal costs.
“We are both OAPs and we haven’t got that sort of cash,” said Keith. “If I could have got the money, I would have taken them to civil court. But I’m not risking losing my property.”
Asked to comment, Jeesal Cawston Park issued a statement: “The coroner concluded that Joanna’s death was due to natural causes and our deepest condolences go out to her family.
"The jury raised concerns at the inquest and we have acknowledged this and seek to continue improvement in the areas raised.
“Cawston Park has received some challenging CQC reports over the past 18 months. In that time many changes have been made in relation to the staffing team, management and reduced capacity of the service.”
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