When something goes wrong in health and social care, the people affected and staff often say, "I don’t want this to happen to anyone else." These 'Learning from safety incidents' resources are designed to do just that. Each one briefly describes a critical issue - what happened, what CQC and the provider have done about it, and the steps you can take to avoid it happening in your service.
Hypothermia can develop in vulnerable people after a relatively short exposure to cold weather. It can even develop after a small drop in room temperature.
Many people who use health and social care services may be at risk of developing hypothermia. They include:
- older people in care homes and receiving care at home
- people with reduced mental capacity, reduced mobility, or a sensory impairment
- people who cannot communicate that they are exposed to cold
The risks to people are serious
In November 2016 an ambulance was called to a care home and found a woman suffering from severe hypothermia and pneumonia. She had been a resident for five years, had generally been well, had full capacity, and used a wheelchair.
The care home was an old, poorly-insulated building with high ceilings and large rooms. Its two boilers, which provided heating and hot water, had both failed. The window in the woman’s room had a broken catch, which meant that the window could not be closed properly.
Staff had not carried out checks on the woman during the previous night, despite her ill health and the lack of heating. They also did not respond to her deteriorating health during the day.
The woman was admitted to hospital, but sadly passed away that afternoon.
Action taken by CQC
CQC continued checks on the home alongside the local authority and environmental health department. We took urgent action to restrict admissions and re-admissions to the service. We also issued a notice to propose to cancel the provider’s registration.
The last person moved out of the service in May 2017 and the provider’s registration was cancelled in June 2017. CQC continue to look at further action against this provider in line with our enforcement policy.
The local authority safeguarding adults board commissioned a review into the woman’s death. The report was published on 12 December 2018.
What can you do to avoid this happening?
Unfortunately, because vulnerable people are susceptible to hypothermia this sort of incident is not uncommon. A similar incident happened in November 2012, when a 91-year-old woman died of severe hypothermia in a care home. She had not been given any hot food or drink as she spent her last day asleep in her room. Her body temperature was so cold it would not have registered on a standard thermometer.
The provider was found to have failed in their duty of care, was guilty of systemic failures and was fined £1.6 million. The judge said this was “an accident waiting to happen”.
These incidents happened in care homes, and demonstrate how important it is for providers to have contingency plans to keep their residents warm – particularly over the winter months.
People receiving care at home may be at a greater risk. NICE have produced a Quality standard for Preventing excess winter deaths and illnesses associated with cold homes. This includes priority areas for home-care staff to:
- ask vulnerable people, at least once a year, whether they have difficulty keeping warm at home
- consider room temperature when they are making home visits
- ensure good communication between agencies. This is to identify and address any needs and to avoid duplication.