A coroner has ruled neglect contributed to the death of an elderly resident in a Leek care home a month after a fall.
Dementia sufferer Eric Chattaway sustained a broken hip and extensive bruising all over his body when he fell at Hillesden House Rest Home, in Leek, while staff were busy elsewhere.
North Staffordshire Assistant Coroner Anthony Curzon said on Tuesday that the fall on December 6 contributed to the 87-year-old’s death by a chest infection on January 7, and it was a result of neglect by staff. at the care home.
Mr Curzon said: “I am satisfied there was a gross failure on this occasion and I record this as accidental death which was contributed to by neglect at the care home.”
An inquest into the retired vehicle engineer’s death heard he had fallen at the home on five previous occasions, this was not the first time he had fallen while resident and there were failings in how these were reported to his family, social services and the Care Quality Commission (CQC).
Social worker Simon Hampl also raised concerns about ‘inadequate’ staffing levels at the home at the time of the incident.
Pat Starkey, manager of Hillesden House, told the hearing two workers were with a nurse in a bedroom, helping another resident into a hoist, when Mr Chattaway fell. This meant only one staff member was looking after the remaining residents in two lounge areas downstairs.
She said she did not know Mr Chattaway’s family were not told about the previous falls. She said: “I didn’t realise there were six falls. I thought there were four.
“One I know Mr Chattaway had been told about because it stated it in the care plan, but the other ones I don’t know why he wasn’t told. The people on duty inform the family and make them aware of what’s happened. All I can do is apologise for that because I don’t know why they didn’t inform the family.”
Mr Hampl, an employee at Staffordshire and Stoke-on-Trent Partnership Trust who investigated the fall, told the inquest he was surprised by a CQC assessment which found staffing levels at the home on the day were ‘acceptable’.
He said: “When I spoke to the CQC they confirmed,despite their authoritative position, they have got no formal assessment tool to judge whether staffing levels are adequate or not, which surprised me.
“From the home’s perspective the staffing level was adequate. It was just the way the staff were used that day which was the crucial issue.”
Referring to how the home dealt with Mr Chattaway’s previous falls, Mr Hampl said: “They weren’t reported in line with the reporting framework. Had that happened, that might have flagged up another more formalised pathway in terms of looking at the accidents in a more forensic manner.
“They were reported to some extent on the home’s own paperwork but that wasn’t communicated to all parties, essentially the most important party being the family.”
Pathologist Mark Stephens gave Mr Chattaway’s cause of death as bronchopneumonia, as a result of dementia (Alzheimer’s disease in old age) and osteopotic fracture of the femur.
His son Nicholas Chattaway, aged 50, from Leek, hopes lessons will be learnt. He said: “I feel my father’s life was cut short due to the fall. I am disturbed and unhappy about the management of the care home.”