Woman's care home death sparks coroner's concerns

The coroner said Ms Dewey's death was contributed to by "neglect" from Heeley Bank Care Home

An elderly resident of a care home in South Yorkshire died after staff did not use the appropriate equipment to help her stand, an inquest has found.

Mavis Dewey, 89, died on 29 March at the Northern General Hospital, six days after a fall at the Heeley Bank Care Home in Sheffield.

South Yorkshire West’s assistant coroner Steve Eccleston said in a prevention of future deaths report that agency staff at the home had, on occasion, failed to read care plans to keep residents safe.

In his report, Mr Eccleston warned the operator of the home, Monarch Healthcare, that more residents could die if action was not taken to ensure care plans were read.

Mr Eccleston said in his report that on 23 March, Ms Dewey had been assisted to stand by two members of staff in her own room at Heeley Bank.

However, staff had used the wrong equipment to help her get up, which was in breach of a care plan which stipulated she needed two members of staff to help her stand, together with a standing aid and sling.

According to Mr Eccleston's report, a standing aid was present in Ms Dewey's room, as was a Zimmer frame, "however it was not possible to establish how the Zimmer frame got there".

The Local Democracy Reporting Service said Mr Eccleston was told that Ms Dewey had asked to use the toilet after the two members of staff had helped her stand.

The home said she had then been left with one carer and was supported on the Zimmer frame.

However, her legs had given way and she had fallen to the floor and sustained a severe gash to her right leg.

'Timetable for action'

Ms Dewey was taken to hospital where a fracture to the right proximal tibia and fibula was found, the coroner said.

His report added: "Despite appropriate care in hospital, Mavis did not recover and she died there."

Mr Eccleston said Ms Davison, for Monarch Healthcare and Heeley Bank, had accepted it was "entirely inappropriate for the two members of staff to use the Zimmer frame to help Mavis stand, but this is what they did".

There was "no good reason" for the carers' actions, he said, and he concluded that "this failure led directly to Mavis’ eventual death".

Ms Dewey's death was contributed to by "neglect" from Heeley Bank Care Home, he added.

Mr Eccleston said in his report that he was concerned the "admitted failure of agency staff, on occasion, to read care plans" meant there was "a risk that future deaths will occur unless action is taken".

"I believe you as the chief executive of the Monarch Group and operator of Heeley Bank Care Home have the power to take such action."

Mr Eccleston said Monarch Healthcare must respond to his findings by 3 October, and that response "must contain details of action taken or proposed to be taken, setting out the timetable for action".

Monarch Healthcare has been approached by the BBC for a comment.

Listen to highlights from South Yorkshire on BBC Sounds, catch up with the latest episode of Look North or tell us a story you think we should be covering here.