Mrs O’Connor, 89 years old, had a history of dementia and was a resident at Altham Care Home, Blackburn. She had resided at the home since 2015 and was subject to a Deprivation of Liberty Safeguarding Order. On the morning of 30th December 2017, she managed to abscond from the care home and was last seen by staff at 05:00 hrs. Later that morning, at approximately 07:50 hrs staff did a handover and became aware of her absence and went looking for her. At approximately 09:30 hrs, she was found by a member of staff in the back garden of the care home behind the shed on the ground, wet through and very cold. On arrival of Paramedics, Mrs O’Connor was so cold, that paramedics were unable to detect a temperature and she was hypothermic. She was transferred to the Royal Blackburn Hospital where she sadly died later that morning.
The medical cause of death was recorded as:
2. Alzheimers disease dementia
An inquest was opened into Mrs O’Connor’s death and took place on 12th August – 14th August 2019 at Preston Coroner’s Court. At the start of the case, legal submissions were made on behalf of Mrs O’Connor’s family that the Coroner ought to hold an Article 2 compliant inquest which would look at the wider circumstances surrounding her death. The Care Home made submissions to the contrary however the Coroner was satisfied that Mrs O’Connor was in state detention at the time of her death and it was noted that her placement at Altham Care Home had been funded by the local authority.
On the basis the Coroner was satisfied that Mrs O’Connor was in state detention at the time of her death, the inquest was heard with a Jury.
The inquest explored the following areas;
How Mrs O’Connor was able to leave the care home and find herself outside the building. The inquest was to explore what route she took and what were the physical barriers in place at the home to prevent her leaving;
Systems, practices and policies in place to supervise residents at the home and where appropriate, to prevent them from leaving the property.
Evidence was heard from a number of witnesses at the inquest who were responsible for Mrs O’Connor’s care at the home. It was accepted that no further checks had been carried out after 05:00hrs as they should have been and it was unclear whether the buzzer that would alert staff to Mrs O’Connor opening her door was working and/or switched on.
Evidence was also heard from the Lead Investigator of the Adult Safeguarding Investigation carried out by Lancashire County Council following Mrs O’Connor’s death. A number of recommendations were made to Altham Care Home following Mrs O’Connor’s death which included recommendations around the automatic front door at the home and the bedroom door sensors. Concern was raised that the front door was opened for a considerable amount of time and posed a possible safety risk. Concern was also raised that the bedroom sensors could be turned on and off each time staff check residents which could lead to a risk of staff not turning them back on.
The Jury returned a conclusion of Misadventure and in answering how, when and where she came by her death recorded the following;
Security procedures were in place but were inadequately followed
Staff sickness procedures were incorrectly followed leading to reduced staff for the night shift;
Inadequate training of whereabouts procedure led to confusion over checking requirements;
Reduced staffing level contributed to unsatisfactory levels of whereabouts checking;
Inaccurate and inadequate record keeping contributed to insufficient information on handover;
Failure to follow security procedures led to the room buzzer being disabled;
Failure to follow security procedures led to the front door being unsecured.
They further recorded that after 05:00 hrs on the morning Mrs O’Connor absconded that:-
“Mrs O’Connor was able to leave her room undetected and roam the home. She found the front door unsecured and exited the home. Finding herself outside she followed a path until it was blocked by a container. She remained there until she lost consciousness. She then succumbed to the cold. She was taken by ambulance to the Royal Blackburn Hospital where she passed away.”
The family of Mrs O’Connor said;
The Inquest conclusion reached by the Jury was much more than we hoped to achieve. We are very grateful to the inquest team at Farleys for securing funding, arranging representation and all their hard work both before, and during the Inquest.
Kelly Darlington, Solicitor for the family said;
“This is an extremely tragic case where an elderly and very vulnerable lady suffering from dementia was able to abscond from what was meant to be a place of safety. Had procedures been followed and staff been more vigilant the outcome could have been very different.”