A 95-year-old died of hypothermia and pneumonia after both boilers failed in a Norfolk care home, where residents had to rely on temporary heaters and hot water being carried in jugs.
And a new report has revealed how organisations which should have scrutinised the measures the home was taking to keep its residents warm were slow to act and carry out checks.
The death of the woman, known as Ms E, after she was admitted to the Norfolk and Norwich University Hospital, prompted a report by the Norfolk Safeguarding Adults Board.
It does not name the care home where Ms E, but it is understood it was Pine Heath Care Home in High Kelling, near Holt.
The home was closed by its owner in May last year, after moves to cancel its registration.
Following the death of Ms E at the Norfolk and Norwich University Hospital on November 9, 2016, Norfolk police and Norfolk County Council investigated whether criminal offences had taken place. The owner and manager were arrested on suspicion of manslaughter by gross neglect, but no criminal proceedings followed.
The report details how the home was an 'old, poorly-insulated building', with the heating and hot water running on two boilers dating back to the 1960s - and had both had condemnation notices issued on them in 2013.
One failed in summer 2016 and the second failed in mid-October 2016, so the home 'lacked hot water and heating for a number of weeks'.
Temporary measures, including portable heaters, temporary water heaters and hot water being conveyed in jugs were in place at the time of Ms E's death, with the home's owner out of the country.
Those measures were being monitored by the Care Quality Commission (CQC) and the quality assurance team at County Hall's adult social care department.
But the review highlighted the 'slow start' in the CQC and Norfolk County Council working together to check the situation. Days passed between family members raising concerns that the home had not had hot water for two weeks and the CQC and Norfolk County Council making calls and checks.
The report said: 'There were initial delays in investigating the situation and a lack of proactive response by some of the agencies who held key responsibilities.'
The CQC did not contact the care home, or anybody else for three days after a family member called with concerns on October 28. While there were telephone checks that temporary measures were in place, it was not until November 8, the day before Ms E died, that they decided an urgent inspection was needed.
Norfolk County Council's enquiry desk had learnt of the issue from a relative on October 31, but did not raise it as a safeguarding concerns and only emailed adult social care's quality assurance team the following day.
While the quality assurance team did visit the care home on Friday, November 4, the report says they reflected they should have taken immediate action earlier - and done more to check the actions being taken were in place.
Neither the council or the CQC had checked the logs staff had been keeping of room temperatures and when ambulance crews arrived to help Ms E, they found the home's environment 'extremely cold'. They did their own review of other residents.
On December 12, the Norfolk and Norwich University hospital expressed 'grave concern' to the county council about the residents, amid concerns about infection control and legionella.
There were restrictions on new admissions and a proposal to cancel the homes registration. The owner closed it in May last year.
The report says: 'All the agencies were hampered in their efforts by the attitude and responses of the care home owner. His disengagement remained a serious impediment to effective management of the ongoing concerns.'
The report states: 'It is, of course, impossible to know whether a more proactive response when the problems first came to light would have made any difference to the outcome for Ms E.
'Arguably, work with the care home to secure a solution could have started earlier, but given Ms E's medical condition, which itself could have contributed to her hypothermia alongside the temperatures in the care home, no firm conclusions can be drawn.'
At an inquest into her death, the coroner noted that she had not received antibiotics prescribed her GP the previous day and also that the care home's boilers were broken.
'The evidence does not reveal which developed first or to what extent these two issues contributed to her death', the coroner concluded.
The case sparked a number of changes and recommendations, including improving communications between organisations.
What they said:
The Norfolk Safeguarding Adult Board
Joan Maughan, chair of the Norfolk Safeguarding Adult Board, said: 'Ms E sadly died of pneumonia and hypothermia in November 2016 and it is clear from this review that there were failures in health and safety standards at the care home where she was living.
'Safeguarding Adult Reviews take place so that we can all learn lessons from what has happened and look at what changes might need to be made to prevent tragedies from happening in the future.
'It is therefore particularly concerning that the owner of the care home would not engage with this review.
'Providing adequate hot water and heating should be among the minimum expectations in a home looking after older and vulnerable residents and it is clear that standards fell well short of what we as a board would expect.
'The review includes recommendations for many of the agencies that were involved with monitoring the quality of care and safety.
'They could have worked more effectively together, followed up concerns more robustly and used professional curiosity to challenge each other and the owner.
'However, it important to emphasise that there was some very good practice in this case, particularly from the paramedics who visited the home on the day Ms E died.
'Their quick actions identified the risk to Ms E and others and ensured other residents received the healthcare they needed. 'The multi-agency response after Ms E's death was also strong and rapid and the home has since closed. The actions after Ms E's death show that multi-agency safeguarding procedures can and do work when they are escalated.'
Norfolk County Council
James Bullion, executive director of adult social services, said: 'The failure of this care home to adequately care for its residents and keep them safe is particularly distressing.
'We accept the recommendations of this safeguarding adult review and also share the board's concerns that the owner of the home would not take part in this review.
'As a council we do not have any enforcement powers but we do monitor care quality as part of our contracts with providers and we can and do arrange alternative care for residents where there are serious concerns about quality or safety.
'With more than 360 care homes in the county, looking after about 9,000 residents this is a significant task.
'In this case we visited the home to seek assurances that steps were being taken to keep residents warm and safe. However, we could have looked for more evidence that these steps were being carried out.
'We want people living in Norfolk's care homes to be safe and receive good care.
'We know that for most people the quality of care is very good and we expect 85pc of care homes to be good or outstanding by the end of March 2020.
'We are looking at how we can strengthen the capacity of our Quality Assurance team so that we can increase our monitoring. Anyone who has concerns about the care or safety of an adult should call 0344 800 8020.'
The Care Quality Commission (CQC)
A spokeswoman said: 'CQC was part of the review regarding the death of a lady who had been receiving care in Norfolk and we are aware of the outcome published by Norfolk Safeguarding Adults Board.
'We have examined what happened in this case and are working with the local authority to ensure that any lessons from the review are learned. Our sympathies are with the family of the lady who died.'
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