A frail pensioner with Alzheimer’s Disease died after “a distressing catalogue of events” sparked by a fall from a wheelchair in a Harrogate care home, an inquest heard.
Joan Conway, who was 87 when she died on January 9 last year, suffered spinal fractures in the fall at The Crest residential care home in Harrogate, which happened after staff failed to secure her into her wheelchair – despite the requirement being included in her care plan.
Mrs Conway, who lived in the Harehills and Guiseley areas of Leeds before moving to the Bupa home in 2008, died in Harrogate District Hospital 14 days after the fall on Boxing Day 2010.
In what Harrogate coroner Rob Turnbull called “a distressing catalogue of events”, Mrs Conway wasn’t taken to hospital until two days after the fall and did not undergo an x-ray for four days.
The day after she returned to The Crest with a neck collar and orders for complete bed-rest, she was found by her daughters Susan Wright and Penny Hunt “slumped in a chair, dehydrated and with the blood-soaked collar covering her mouth and close to her mouth”.
Dr Daniel Scott, who carried out the post-mortem examination, told Harrogate Coroner’s Court that Mrs Conway’s fall “contributed” to her death from bronchial pneumonia.
Recording a narrative verdict, Mr Turnbull said: “It seems perfectly apparent to me that they [the staff at The Crest] had not read the care plan and were not aware of the need for Mrs Conway to be secured into the wheelchair. It’s clear she wasn’t secured in the wheelchair and this may have prevented her fall and her death at the time.”
The inquest heard that Mrs Conway, who was unable to walk or talk, was about to go for a bath with care assistants Williedon Santon and Rhoda Pabros when the fall occurred.
Giving evidence, Mr Santon said his colleague had gone to fetch towels and bedding and he was collecting clothes from the wardrobe when Mrs Conway fell head-first out of the wheelchair.
Both he and Mrs Pabros admitted they had not read Mrs Conway’s care plan, while senior carer Tomasz Lugouski told the inquest he didn’t send Mrs Conway to hospital because she only had a small carpet burn on her forehead and didn’t seem in pain.
After Mrs Conway’s death Ishtiaq Mohammed, North Yorkshire County Council’s care services manager for Harrogate West, carried out a safeguarding investigation and recommended that The Crest re-visit their policies on head injuries, care plans and the use of seatbelts.
Manager Andrea Pearson said improvements had been made.
However, Mr Turnbull said he was “concerned” that there appeared to be no formal system in place to ensure that staff had read the care plan.
He told the inquest that he was going to write a Rule 43 letter to Bupa to ensure a system was implemented to prevent deaths like Mrs Conway’s in the future.
After the inquest, Susan Wright, from Alwoodley, said: “We want to prevent other families going through what we’ve been through and hopefully the letter will ensure that happens. We’re pleased my mum’s death has been attributed to the fall because if she hadn’t had that accident, we hoped she would have gone to bed one night and slipped away peacefully. We feel it’s because of the accident that she isn’t here today.”