only one member of staff was helping Mrs Keogh on the morning of the accident when a risk assessment document said she needed two to help her wash, dress and move from one part of the home to another.
An elderly care home resident died after crashing through a wooden handrail on a first-floor landing and falling to the ground, an inquest heard.
Marjorie Keogh suffered head injuries, broken ribs and severe cuts and bruising in the incident, at Scraptoft Court Residential Home, Leicester.
An inquest at Leicester Town Hall yesterday was told that the 89-year-old, who needed a mobility walker to get about, was being helped down to breakfast when the fall happened, at about 8am on February 6, 2010.
Detective Constable Amanda Thwaites said a police investigation was launched four hours later.
“Mrs Keogh was going down for breakfast with the assistance of a carer and a trolley she used for walking,” she said.
“However, she decided to turn around and return to her room to brush her teeth.
“As she turned, she fell on to her walker with her left hand and reached out for the banister with her right.
“She lost her balance, held onto the banister and fell through on to the ground floor below.”
An ambulance was called and Mrs Keogh was taken to Leicester Royal Infirmary, where she died the following day.
The jury was told she had been a resident at the home for just over a year, having left her own home in Ocean Road, Thurnby Lodge, due to the onset of dementia.
Forensic pathologist Dr Charles Kendall said the cause of death was pneumonia caused by the “multiple injuries” sustained in the fall.
He said dementia and other underlying medical problems were “contributory factors”.
Leicester City Council, the regulatory authority for care homes in the city, and the Health and Safety Executive (HSE) also launched investigations into the accident.
Barry Berlin, advocate for the city council, read out part of a statement given to police by Pamela Frost, Mrs Keogh’s daughter, in which she claimed she had previously raised concerns about the safety of the staircase banister.
“The banister would wobble,” she said. “I reported this a couple of times to carers, saying it was about time they sorted it out as it’s dangerous.”
Giving evidence, care home owner and manager Helen Appleton said there were six members of staff on duty at the time, looking after 24 residents.
She said she had been unaware of concerns about the safety of the banister raised by Mrs Keogh’s family.
Ms Appleton declined to comment on several points after being warned that, under inquest rules, she did not have to answer questions in which she could potentially incriminate herself.
They included why the accident was not reported to the Care Quality Commission for several days after the incident.
She also did not explain why only one member of staff was helping Mrs Keogh on the morning of the accident when a risk assessment document said she needed two to help her wash, dress and move from one part of the home to another.
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