A catalogue of failures which contributed to the death of an elderly care home resident who fell to the ground from a first floor landing amounted to “gross neglect”, a jury has ruled.
Marjorie Keogh died in hospital on February 7, 2010, due to injuries sustained a day earlier in the fall at Scraptoft Court Residential Home, Leicester.
The 89-year-old, who needed a mobility aid to get about, crashed through a wooden balustrade after losing her balance as she was being helped down to breakfast.
A jury at Leicester Town Hall returned a verdict of “accidental death”, but said it was contributed to by “gross neglect”
Speaking after the inquest, Mrs Keogh’s son, Ian, 56 – a senior construction manager from Skegness – said: “Family members are happy with the verdict, especially with the words ‘gross’ and ‘neglect’ in there. What happened to mum was horrific and she must have been so frightened.
“She was a very family-orientated lady and her life should not have ended like this.
“We were shocked by what we heard.
“I think there needs to be a complete overhaul of the entire UK care system.”
Returning the unanimous conclusion at the end of the four-day inquest, the jury foreman said: “There were gross failures in care due to the lack of communication of appropriate procedures – and numerous failings in providing basic care needs.
“Mrs Keogh was in a highly-dependent position due to illness and restricted mobility, with impaired mobility and balance.
“Insufficient care contributed to the fall.”
Mrs Keogh 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.
The inquest heard that only one care assistant had been helping Mrs Keogh when she fell headfirst through a wooden balustrade guarding a first floor landing.
Records showed there should have been two carers, as a personal care plan stated she was at “high risk” of falling.
Family members said they had reported concerns about the stability of the staircase banisters to staff, but these were not recorded or addressed by the home.
Concerns were also raised at the inquest about staffing levels, with some employees working 13-hour shifts, and only four care staff looking after 24 residents on the morning of the accident.
A senior care manager should also have been present, but was not.
The police, Leicester City Council – as the regulatory authority for care homes in the city – and the Health and Safety Executive launched investigations into the accident.
Evidence was given that the balustrade Mrs Keogh crashed through was “entirely unsuitable”, being made of soft wood with an “impact load” of 0.36 kilonewtons (kn) per metre, when British Building Regulations required it to be 0.74kn per metre for a commercial premises.
“A structure made of hard wood compliant with the 0.74kn standard would have saved her life,” said HSE safety inspector Mark Shearon.
It also emerged during the inquest that there are no records of Scraptoft Court – built in 1997 by then and current co-owner and builder Dinesh Gokani – ever being given a building completion certificate by Leicester City Council.
Issues outstanding included the insulation of doorways and cavities to prevent the spread of fire.
Another matter which surfaced during the inquest centred on nobody calling the police for more than four hours after Mr Keogh’s accident, and the failure of the home to report the accident to the city council’s environmental health and safety team.
Coroner Donald Coutts-Wood said he would be writing to Scraptoft Court to demand evidence of a building completion certificate – and that the staircase involved in the accident now complied with safety standards.
He will also be writing to care home regulator the Care Quality Commission and to the Chartered Institute of Environmental Health.
Mr Coutts-Wood said he was worried that there could be many more residential homes, both in Leicestershire and across the UK, where construction and staircases do not comply with building regulations.
No-one from Scraptoft Court was available to comment.
Read more: http://www.leicestermercury.co.uk/Care-home-criticised-following-tragedy-pensioner/story-20248445-detail/story.html#ixzz2mLv6lmzy