Derby woman's wheelchair death caused by neglect, coroner rules

The hip fracture of Shirley Froggett was initially missed, an inquest heard

Neglect and failure to follow a care plan were factors in the death of a nursing home resident who fell from her wheelchair and fractured her hip, a coroner has ruled.

Shirley Froggett, 84, was injured at the New Lodge Nursing Home in Derby in September 2018 and died from pneumonia after surgery two months later.

Staff had wrongly said Mrs Froggett had been strapped in, the inquest heard.

Coroner Dr Robert Hunter added some staff lied over Mrs Froggett's death.

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In a narrative conclusion, the Derby coroner said Mrs Froggett died as a result of an accident that was contributed to by neglect.

"The failure to follow the care plan was directly causative of Mrs Froggett's death," he said.

A buckle on the lap strap on Mrs Froggett's wheelchair had been missing for a period of time prior to her fall and Dr Hunter described its continuing use as a "gross failure."

There was also a failure to send Mrs Froggett to hospital after the fall as per the nursing home's protocol, but that failure did not contribute to Mrs Froggett's death, he said.

He added the inquest could have been concluded a lot earlier if some members of staff had not chosen to lie about the circumstances of Mrs Froggett's death.

Dr Hunter said the home had failed to undertake a robust and comprehensive investigation into the fall and he planned to ask the Care Quality Commission (CQC) to investigate whether the nursing home was auditing compliance with care plans properly.

He told the inquest: "I'm not satisfied that it's safe and staff have been following care plans."

Nursing home staff later accepted Mrs Froggett had not been strapped in as per her care plan

Earlier, the inquest heard Lindsey Foster, a manager at the home, had not picked up on the fracture or sent for an ambulance on the day.

Appearing at the inquest earlier, Mrs Foster admitted Mrs Froggett should have been sent to hospital "there and then".

Two members of staff at the home in Mickleover previously told the court Mrs Foster had ordered employees to say Mrs Froggett was strapped in when the fall happened.

The coroner reminded Mrs Foster that under law, she did not have to answer certain questions that may incriminate her.

He then asked her if "you and possibly others attempted to cover up the seriousness of what happened to Mrs Froggett".

She replied: "No comment."

'I'm so sorry'

The court was told Mrs Froggett - whose fall was not witnessed - had dementia and could not walk.

Mrs Foster said she monitored Mrs Froggett's blood pressure and oxygen after finding her in a "semi-prone position" on 19 September.

Mrs Froggett, who was on anticoagulants, told her she was not in pain, the court heard, but later developed bruising to her forehead and left side.

"The plan was to monitor Shirley and contact medical assistance if required," Mrs Foster said.

When Mrs Foster returned to work two days later, Mrs Froggett was at the Royal Derby Hospital where she had an operation, and later developed pneumonia from which she died.

Mrs Foster - who the inquest heard has been struck off as a registered nurse - said: "I did not dispute it. I let Mrs Froggett down. I don't feel I could be a nurse. I should have sent her to hospital and I feel I don't deserve to be a nurse and I have not done anything else in care.

"I'm so sorry, I should not have done it."

With her voice breaking, Mrs Foster said: "I am truly really, really sorry. I have felt like this from day one."

Mrs Froggett died two months after the fall

Following the inquest conclusion, Mrs Froggett's family said they wanted to raise awareness of her case to show "the vulnerability of the elderly in care".

"Mum put her faith in the care system, we put our faith in the care system but sadly the care system failed mum," they said.

"We have received apology after apology, but none of these apologies will bring her back.

"Those of you who lied, to justify your own ends, will have to live with the consequences of your own actions."