Care home safe holding has to account for risk between residents, not only between staff and residents.
Dennis Bryant died in November 2013 at the age of 90 after fellow Alzheimer’s patient, Michael Hall, went into his room in Westcott House Nursing Home in Dorking and punched him several times in his bed.
The attacker, diagnosed with Alzheimer’s in June 2013, was admitted to East Surrey Hospital with a police escort that August after an incident at a day care in which he shouted and threatened others with his walking stick.
Care home safe holding: what the coroner found
Delivering a narrative conclusion, coroner Alison Hewitt said she would compile a report making recommendations to West Sussex County Council over the withdrawal of a safeguarding alert on Mr Hall and their risk assessments, to Surrey and Sussex Healthcare Trust about its risk assessment protocol and the wording of crucial forms, and to the Secretary of State for Health about streamlined information gathering between authorities and guidance for the protection of bedbound patients.
The coroner’s investigation exposed systemic failures: a withdrawn safeguarding alert, inadequate risk assessments, and poorly worded forms that left a bedbound 90-year-old unprotected.
Lessons for Care Providers
This case highlights — yet again — the need for agencies and care home managers to recognise a history of violence as a significant risk factor when admitting a resident to a care home.
There continue to be tragic stories of lives ruined, changed, or prematurely ended when residents with Alzheimer’s or other forms of dementia who present with violence are not properly risk assessed. This puts staff, other residents, and ultimately the organisations themselves at risk.
⚠️ Critical: A history of violence must be recognised as a significant risk factor at the point of admission. Without proper risk assessment, staff, residents, and organisations are all exposed to preventable harm.
It also highlights the need for staff in care homes to be trained to deal with violent incidents if and when they occur. The quality of that training depends directly on the quality of risk assessment and admission policies.
Just last week, a care home owner was jailed for gross negligence manslaughter after failures in care led to the death of an 86-year-old resident:
Negligent care home boss jailed for corporate manslaughter after widow, 86, died weighing four stone
Read the full report: Get Surrey — Alzheimer’s patient ‘looked like he had gone 10 rounds with a boxer’
