'Rules not followed' at home where 7 people died

From left: Susan Skinner, Jean Hartley, Stanislawa Koch and Ronald Bampfylde were four of the seven residents who died

Measures to protect residents from Covid at a care home where seven elderly people died were not “effectively or consistently” followed by staff, a coroner has ruled.

William Wilkinson, 102, Doris Lockett, 92, Roy Gilliam, 96, Jean Hartley, 81, Susan Skinner, 70, Ronald Bampfylde, 92, and Stanislawa Koch, 93, all died in March or April 2021 after contracting coronavirus at the Holmesley Care Home in Sidford, Devon.

The deaths all came at the height of the Covid pandemic when rules were in place intended to protect residents from infection.

After the inquest on Thursday, Mick Koch - son of Ms Koch - said he wanted to take the matter further and see it scrutinised at the national Covid inquiry.

Alison Longhorn, area coroner for Devon, Plymouth and Torbay, said that while there were proper processes at the home these “were not effectively or consistently followed” by all the staff working there.

Mr Koch said he had already approached the Crown Prosecution Service (CPS) and police about whether they could investigate what happened at the home.

He said he wanted to take the matter to the inquiry set up to examine the UK's response to the pandemic.

"I'm certainly going to take this to the national inquiry on Covid, but I'll wait to see what I get back from the police and CPS," Mr Koch said after the inquest concluded.

Mick Koch said he has contacted police and the CPS about the deaths

Earlier in the inquest, it was heard two staff members - manager Joanne Burchell and nurse Christos Provistallis - had been arrested on suspicion of ill-treatment or wilful neglect in connection with the deaths.

CPS officials decided there was not a realistic prospect of conviction.

Allegations were heard during the inquest that Mr Provistallis refused to wear a face mask after claiming "Covid was a conspiracy".

Others alleged Ms Burchell had not sent sick staff home due to shortages and had ignored positive lateral flow test results.

The inquest heard a member of staff at Holmesley Care Home in Sidford, Devon, refused to wear a face mask during the pandemic

Will Neal, a director of the company which owned the home, said he was "disappointed" and "shocked" and described some of the allegations made as "absolutely unacceptable".

Ms Longhorn said while she acknowledged there had been issues, she had not found there to be negligence at the care home.

She added: “We have heard much evidence that some staff at Holmesley did not effectively or consistently follow clearly defined processes regarding infection prevention and control and that their practice of not doing so potentially put that home at risk of infection.

“I would highlight that evidence heard at this inquest related to only some staff at one care home."

The coroner also acknowledged recent CQC reports which indicated there had been improvements at the home.