Staff at Rawmarsh care home criticised over pensioner fall death

The Doncaster Coroner,  Ms Nicola Mundy, said she would write to Rotherham Borough Council over the treatment of 90-year-old Phyllis Broomhead, who died two years ago while living at council-run Lord Hardy Court.

The coroner also questioned the effectiveness of a new staff training regime and said there was still work to be done to improve record keeping and decision making at the 60-bed home in Rawmarsh.

Ms Mundy said the home’s management should have met with other agencies including the council to look into why Mrs Broomhead had suffered a series of eight times in three months, the last of which led to a brain injury and her death in June 2013.

The inquest heard that care and health staff did not want to impose on Mrs Broomhead’s liberty.

But the coroner ruled on Monday that the vulnerable pensioner needed more safety equipment, closer monitoring and quicker medical attention.

“Mrs Broomhead was assessed as not needing nursing care,” Ms Mundy said.

“But for residents like her, who are at risk of falls, it appears there needs to be closer scrutiny.”

Mrs Broomhead, who suffered dementia and other health complaints, was described as an “independent lady”, who would not be bedbound.

She normally moved with help from two carers, but would often try to reach her bathroom alone during the night.

Carers told the court how they put pressure sensors in her bed which would sound an alarm when she tried to move, but they did not always reach her upstairs room in time to stop her falling.

A physiotherapist asked for bed sensors linked to staff pagers so they might respond quicker, but these were not acquired.

Ms Mundy also criticised the home’s safeguarding procedures.

Doctors had raised care concerns after treating Mrs Broomhead’s second fractured hip but safeguarding manager Jill Weatherall found that no reassessment of Mrs Broomhead’s care was needed.

Ms Mundy said Ms Weatherall should have involved other parties in her decision.

“There was then a screening progress to determine whether to exit safeguarding or have a care strategy meeting,” said Ms Mundy.

“I conclude that the threshold for a multi-agency meeting was met.

“It would have been prudent to examine why Mrs Broomhead had all these falls and whether extra measures were needed.”

Mrs Broomhead was discharged from hospital after surgery on her hips and returned to Lord Hardy Court.

This decision, Ms Mundy said, was “made entirely too lightly”.

She added: “I acknowledge that falls cannot be prevented entirely, but I am concerned that they continued.”

The court heard that care staff considered giving Mrs Broomhead a lower bed, but decided against it.

They were also advised to check on her half-hourly through the night, but this did not happen.

Ms Mundy said: “I am not dissuaded that lowering her bed would have been inappropriate.

“I heard Mrs Broomhead would not have got out of bed, or would have taken longer. This would have given more time for staff to respond to alarms.”

She added: “I am far from persuaded that checks were carried out with the frequency with which they should have been. I doubt even hourly checks were being made.

“I believe frequent checks would have reduced the occasions Mrs Broomhead tried to get out of bed.

“It was clear that she was at high risk of falls. I conclude that further measures could have been put in place.”

The court also heard that carers did not seek medical help immediately after Mrs Broomhead’s last fall, which happened she tried to reach the toilet and caused a brain injury.

Reaching a narrative conclusion, the coroner noted: “Following a fall and serious injury carers should have sought medical advice, but they did not.”

A nurse did not see her until 7am, by which time she was in a critical condition with an unsurvivable hematoma, Ms Mundy said.

Sam Newton, Rotherham Council’s interim head of adult services, said the authority offered its “sincerest condolences” to Mrs Broomhead’s family.

She said the authority had reviewed its protocols since her death, adding at they would await the coroners report.

“We are determined to learn from this tragic event and will continue to work towards providing the best possible services into the future,” Ms Newton said.