Care home missed chances to protect frail woman

Lawyers for the care home said improvements had been made since the incident

A care home "missed opportunities" to protect a vulnerable woman, who died of a bleed on the brain just weeks after a fall, an inquest found.

Maureen Woollen was found on the floor in her room at Deerlands Residential Home in Sheffield on 3 October 2023, the day after being discharged from hospital.

Senior coroner Tanyka Rawden said the home should have conducted a falls risk assessment on Ms Woollen when she arrived, and missed opportunities to seek medical attention on two separate occasions after she fell.

Lawyers representing the care home owners, SheffCare, said new leadership at the venue had overseen improvements since the incident.

Ms Woollen was readmitted to hospital on 13 October with "intracerebral haemorrhage" – a type of stroke when a blood vessel in the brain ruptures.

She died 18 days later as a result of this, a Prevention of Future Deaths (PFD) report by the coroner said.

The report said that while Ms Woollen had been at “a high risk of falls" due to various factors including her dementia, her frailty and the side effects of her medication, the care home failed to conduct a falls risk assessment upon her arrival.

A "fresh big bruise and a lump on her right forehead and temple" were found by staff on 6 October, three days after she fell.

While the team leader had been notified and a decision to call an emergency care practitioner was taken, the call was never actually made, the coroner said.

'Changes and improvements'

Ms Rawden said between 6 and 13 October there had not been references to Ms Woollen’s facial injuries in the care notes.

In the meantime, the inquest also found that on 11 October staff had noticed a “decrease” in Ms Woollen’s food and drink intake.

However, this had not been recorded in the care notes and medical assistance had not been sought either.

In a response to the PFD, lawyers for Sheffcare said a new director of quality and care had been appointed since Ms Woollen's fall.

The firm added she had been “implementing changes and improvements at the service”.

Through her leadership, the response said, Sheffcare had reviewed its relevant policies and guidance including falls and risk assessment and admission policy.

The law firm said following Ms Woollen’s fall, a so-called “huddle” was carried out and staff were reminded of policies about falls risk, documentation, and escalation, the Local Democracy Reporting Service reported.

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