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Fakenham woman died of natural causes after deteriorating at care home, inquest told




A Fakenham woman whose condition deteriorated during her time at a care home died of natural causes, an inquest has heard.

Veronica Tomlin, 79, died at Lynn's Queen Elizabeth Hospital on September 12, 2019, of bronchopneumonia – having been admitted from Bilney Hall care home in East Bilney 11 days earlier.

Norfolk Coroner's Court heard on Tuesday that the retired civil servant became a resident of the home in April last year, following the death of her husband.

Norfolk Coroner's Court in Norwich
Norfolk Coroner's Court in Norwich

The family of Mrs Tomlin – who was also known as Veronica Harrison – felt she was no longer able to live on her own, the court was told.

Mrs Tomlin's stepdaughter Karen Hunt said, in a statement read to the court, that she had concerns about her mother's care while at the home.

She said she had written four pages of information about what her mother liked to read, watch on TV and eat.

Mrs Hunt said she had settled in "reasonably well" but she was concerned that carers did not use the information she had provided.

She told the court that she also found her mother dirty upon her visits to the home, and felt concerned about how frequently she was given personal care.

"She was in a poor way until her admission to hospital," Mrs Hunt added.

The inquest also heard from carers who had been working at the care home at the time.

They said that during Mrs Tomlin's time at the home, her behaviour was "variable" – but she would often refuse food and drink.

Nicola Irons, a senior carer, said in a statement read to the court: "I tried to give her a drink and she clenched her lips. We were unable to get food past her lips. This is something she did frequently."

The court heard that there was a 'repositioning programme' in place for Mrs Tomlin during July and August, after she developed pressure sores, in an attempt to heal the sores and prevent more from developing.

Bilney Hall care home manager Nikki Shaw told the inquest that when Mrs Tomlin arrived at the home, she had a low Body Mass Index (BMI), and so her food was enriched and she was given high-calorie homemade milkshakes.

But in July and August, as she spent more time in bed due to the pressure sores, and she "liked to do things for herself", it became harder to "get her to eat and drink".

Mrs Shaw admitted there were a "few gaps in her records" but said Mrs Tomlin was given personal care at least twice a day. She said record keeping had since been improved.

"What was clear, having reflected on all of this, is that food and fluid charts in particular weren't being kept up-to-date as much as they could be," she added.

"I really feel for Karen. I'm sorry she doesn't feel we got things right for her mum, but we have learned from it and we will be able to prove that we have been doing these things in the future."

The inquest heard that, as Mrs Tomlin's condition deteriorated and she continued to refuse food and drink, she was admitted to Lynn's Queen Elizabeth Hospital on September 2.

The court was told that, on September 5, when her condition had not improved, it was decided that she would be started on end of life care. She died on September 12 with Mrs Hunt at her bedside.

A post mortem report found that Mrs Tomlin had died of bronchopneumonia, which was contributed to by Parkinson's disease and dementia.

Senior coroner for Norfolk Jacqueline Lake said she was satisfied that Mrs Tomlin had become "more resistant to assistance" during her time in the care home.

"I'm satisfied that the care home did contact the GP surgery when there were concerns and that carers did refer concerns to senior carers, and steps were taken to try to increase her wellbeing," she said.

"However her condition deteriorated so she was admitted to hospital."

She said there had been a lack of continuous record keeping at the care home, but she was satisfied that steps had been taken to improve this.

Mrs Lake gave a conclusion that Mrs Tomlin died of natural causes.


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