Jury criticises care home over bed-fall death

Frail Daphne Watkins had fallen out of bed 16 times in 27 months and on the last occasion became wedged between the mattress and a grab rail, an inquest heard.

The 83-year-old lived at Darwin House in Crosspool, Sheffield, and just a month earlier had trapped her head behind the bed rail but no action was taken by management.

After a four-day hearing an inquest jury found equipment in Mrs Watkins's room was inappropriate and there was no effective policy to pick up on incidents involving residents.

The hearing was told Mrs Watkins had Parkinson's Disease but was fairly independent. She fell out of bed during the night of August 31 last year and died later that day.

Staff found her head trapped by the grab rail which she used as an aid to sit up. Pathologist Dr Kim Suvarna said Mrs Watkins died from a lack of oxygen to the brain.

The pathologist added the death had been contributed to by Parkinson's Disease, which may have caused Mrs Watkins to fall out of bed and leave her unable to free herself.

Mrs Watkins's family had brought the grab rail into the home, which has 25 residents, when she moved there on May 19, 2007, and it was attached to the bed by straps.

The Department of Health issued an alert in February 2007 about grab rail dangers but the home's acting manager Maggie Rodgers said she had no knowledge of it.

The inquest was told an independent nursing expert who carried out an investigation after the tragedy found no evidence a risk assessment had been carried out.

Mrs Rodgers, a former deputy manager who took over the running of the home when the manager fell ill with terminal cancer, said she saw no danger with the grab rail.

She said she was unaware of four incidents in which the pensioner had fallen out of bed, once trapping her head and three times pinning her arm behind the rail.

Mrs Watkins had 26 falls in total at the home and suffered injuries in five.

Sarah Harrison, a senior supervisor who summarised accident reports for management, admitted she had not compiled any involving injuries or grab rail incidents involving Mrs Watkins.

Lorraine Hickey, from the home's management company, told the inquest although Mrs Watkins was at risk of falling out of bed, bed rails could have been just as dangerous as the grab rail.

Mrs Watkins's son Anthony told the inquest his mother was generally very cheerful but was deteriorating with her Parkinson's. He said he was "shocked" when he received a report after his mother's death showing how many falls she had.

"The only ones I was told about by the home were the ones where she ended up in hospital," he said. "I was never told about incidents relating to the grab rail."

Asked by coroner Chris Dorries if he had been aware of the problems with the rail, he replied: "I would have had no hesitation in asking them to take it away."

A snap inspection by the Care Quality Commission after the death in September last year rated the home "poor" and removed its two stars.

But following a recovery plan which included a review of patient care, improved risk assessment and accident reporting, the stars were reinstated in February this year.

After the jury returned a narrative verdict, Mr Watkins said: "The inquest has highlighted areas that need addressing and the important outcome is that this sort of thing does not happen to anybody else."

Sheffield City Council's environmental health department is still carrying out an investigation and has yet to decide whether to prosecute the home under health and safety legislation.

Mr Dorries said he would be writing to the company running Darwin House and the Lord Chancellor to monitor its response in taking future preventative action.

A spokesman from Darwin House Ltd, which runs the home, said last night: "Mrs Watkins was a much loved resident of Darwin House and both the directors and staff were deeply saddened by her death."