A care home resident died of kidney failure due to dehydration after not being given adequate fluids during a heatwave, a coroner has found.

Seventy-eight year-old Fred King, a resident of council-run Birchwood Care Home in Newbury, died on 9 September 2021 of an acute kidney injury caused by dehydration.

In a finding of neglect, assistant coroner Jenny Goldring said Mr King, who was living with dementia, had not received adequate fluids on the two days prior to his death when temperatures rose to 26-30 degrees.

The care home also failed to provide the minimum level of fluid on 10 days during August and September 2021.

There was no care home manager at the service during the three days before Mr King’s death.

The coroner said the council had accepted its record keeping had been inadequate and had introduced a new electronic recording system for recording fluid intake.

The council also pledged to ensure that family complaints were recorded, with its records now audited by four different managers and fluid records checked daily. A full time manager is also now in service.

Ms Goldring said she was drawing the findings to the attention of the CQC so that the home can be kept under review.

A West Berkshire Council spokesperson said: “We send our condolences to the family of Mr King. We note the findings of the coroner and the concerns which were raised at the Inquest. West Berkshire Council was in the process of updating relevant policies and processes prior to the coroner’s investigation into Mr King’s death, including changes to the management structure.   “Ensuring our most vulnerable residents are protected and cared for is one of our priorities.  Alongside a dedicated ongoing improvement programme for Birchwood Care Home, and in conjunction with our obligations under the Care Quality Commission framework, we continue to work with staff across our care homes to maintain high standards and ensure we are providing good quality care to all our residents.”

A CQC spokesperson said: “We have received the coroner’s report into the sad death of Frederick King and are considering any actions we need to take in relation to this.”]

The CQC visited the home following the death of Mr King and found significant failings. A warning notice was issued demanding improvements. A further inspection took place in July. The service is currently rated Requires Improvement.