Coroner Michael Oakley recorded a narrative verdict following the inquest of Jean Jackson, who died at Queen Margaret’s Nursing Home on July 16 last year.
At the time of her death she was suffering from a broken hip. The injury was only discovered port-mortem and sparked a police investigation into staff at the home.
The 67-year-old’s family was seeking answers as to how their mother came to suffer the fracture at the neck of her right femur.
Pathologist Dr Mark Egan told the Town Hall inquest he believed the injury was sustained somewhere around July 9 2015.
She also showed signs of fresh, yellow bruising to the knee, which Dr Egan said would make it most likely the injury was caused by “a fall onto the knee from around three feet in height.”
He said he believed the injury contributed to her death.
Detective Inspector Darren Knight said his investigation was hampered by “gaps” in records of who was caring for Mrs Jackson between July 9 and 10.
He added that “night records” had been “accidentally shredded by a new member of staff”. Giving evidence, the manager of Queen Margaret’s, Jackie Barker, said the night records were simply duplicates of other records, which had been passed to the police.
But Insp Knight said there were crucial hours police had not been able to account for.
The inquest was told Mrs Jackson, who was bedbound and unable to move or speak, was required to be moved every two hours, and this had to be done by two members of staff.
Christine Jaques, a student nurse who occasionally worked at Queen Margaret’s, said she had once seen Malcolm Scrafton, the brother of Mrs Barker and uncle of co-manager Clare Jackson, attending to Mrs Jackson on his own.
She said: “I walked in and she was very low down the bed, if two people were moving someone then they tend to stay where they are in the bed, if you try on your own to remove the sheet, to change the bed, then the person tends to be pulled down the bed when the sheet is moved.”
Mr Scrafton denied this in his evidence, saying he had never moved her on his own. He said he first saw the bruising to her leg on July 15, and reported it to a nurse.
Police tried to bring charges against Mr Scrafton following an investigation, but the Crown Prosecution Service felt there was not enough evidence for a realistic chance of conviction.
Managers for the care home said they were not aware of any occasion where only one person would move Mrs Jackson, saying it was against the home’s policies and Mrs Jackson’s care plan.
Coroner Mr Oakley blasted the home’s record keeping and said “inappropriate handling by one or more persons” led to her suffering the broken bone.
He praised the family for what he described as being “extremely supportive” of Mrs Jackson and at the inquest hearing, adding that like them he would have liked to have ascertained how she had come by her injuries but he had not been able to do so.
“We may never know how her injuries happened,” he said. Mr Oakley believed that someone did know, but had not come forward.
Mr Oakley labelled the records as “appalling” and the matter was now being investigated by the Care Quality Commission. Since Mrs Jackson’s death the record keeping had improved, he added.
He also said he believed Mrs Jackson had been “moved and dropped” while in the home.
In a statement, Mrs Jackson’s children said: “As a family, we would like to express our absolute disgust in the behaviour of some of the individual care staff and all of management of Queen Margaret’s.
“We entrusted this home with the care of our very vulnerable mother, and whilst we appreciate that on occasion human error and carelessness can lead to accidents, for Queen Margaret’s to prolong our suffering following our mother’s painful and distressing death, at the hands of their staff, is inhuman.”
The home’s director, Michael Davey, said he wish he knew what happened.
He said: “After nine months of detailed investigation it cannot be established how this injury occurred or who was involved,
“Queen Margaret’s will continue together with the family to try and find any new information which would allow this current position to be concluded.”