A CARE home resident died after delays in receiving medical intervention, with Herefordshire's coroner warning more deaths could follow if action is not taken.

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 in a Herefordshire care home, the report said, where he was found to have a number of injuries.

These were a left-sided hydropneumothorax (fluid and air in the pleural space in the chest), a fractured right proximal humerus (shoulder), and a lumbar spine end plate compression fracture.


A chest drain was inserted and drained well on the ward, where Mr MacGregor was also receiving intravenous antibiotics, the report said.

He was also reviewed by geriatricians and respiratory physicians, who assisted in optimising his management, and by trauma and orthopaedics for his fracture.

But, the report said, Mr MacGregor's infection markers did not improve after seven days of intravenous antibiotics and antifungals, and he became significantly more unwell.

He was suffering with fluctuations in blood pressure and increasing oxygen requirements, while a chest x-ray showed he had right-sided hospital-acquired pneumonia. 

The report said Mr MacGregor was already receiving the antibiotic of choice for this with no improvement, and the decision was made to start him on the end-of-life pathway.

What are your thoughts?

You can send a letter to the editor to have your say by clicking here.

Letters should not exceed 250 words and local issues take precedence.

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 that, during the course of the inquest, the 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.

"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.

The home must respond to the report, including details of action taken or to be taken, or explaining why no action is proposed, by May 1.