Woman, 94, dies instantly after breaking neck in horror accident at Lytham care home
A 94-year-old woman living at a care home died instantly after falling out of bed and breaking her neck – but staff didn’t realise she was trying to get up because a pressure mat designed to sound the alarm wasn't plugged in.
The inquest into the death of Joan Rutter was also told she may have lay dead for hours before being noticed, with coroner Alan Wilson saying he was “unable to conclude” a 5am check was carried out by staff.
Ms Rutter’s body was eventually found at around 7am when a carer turned up to start their day shift, the court, held at Blackpool Town Hall, heard.
Mr Wilson, who criticised “poor” record keeping at the Riverside Rest Home, in West Beach, Lytham, said urgent changes must be made to avoid repeat tragedies, and told bosses there: “I believe you have the power to take such action.”
The inquest was told frail Ms Rutter, who had kidney disease, a urinary tract infection and a developing bowel issue, was at a “high risk of suffering a fall”.
She was known to wander during the night and too confused to use personal alarms that were available to her.
Mr Wilson said a paramedic was called to the home shortly after 7am on Friday, October 23 last year and pronounced Ms Rutter dead.
He said: “Joan had suffered an unwitnessed fall to the floor between her bed and bedside table."
Staff were unaware she had tried to get up, partly because a falls mat beside her bed “to alert staff when she moved was unplugged”, he said.
The home was unable to explain why it was unplugged, Mr Wilson said, but even if it had been working the two carers covering the night shift would have to have been in a certain part of the building to be alerted.
Mr Wilson added: “In the view of the court, at various times overnight those carers would have been unaware Joan had moved from her bed or otherwise required assistance.”
Ms Rutter was meant to be checked every two hours, the inquest, held on Tuesday, March 2, was told, including at 5am on the day she died, but Mr Wilson said: “The court was unable to conclude this 5am check did take place.”
With the two carers looking after around 24 residents, Mr Wilson said “there would have been periods overnight when Joan may have required the assistance of staff”, and added: “This may not have been available when she needed it and this placed her at risk.
“There would have been times when staff members were in other parts of the building checking on other residents, and they would have been unaware Joan may have been seeking to leave her bed/bedroom.”
With a post-mortem examination finding Ms Rutter died from the neck break and fall, with her underlying conditions contributing factors, Mr Wilson ruled her death an accident.
But he remained concerned enough to write a rare report designed to prevent future deaths.
In it, he said paperwork at the home had a “paucity of entries made during the night shift”, with Ms Rutter’s efforts to wander the rest home “unrecorded”, leaving day staff struggling to “have an accurate understanding of how the residents had presented overnight”, and “potentially unaware of recent important events”.
Mr Wilson also said he was “concerned the night shift operated in a way that meant staff could be unaware residents needed their assistance”.
He said he was aware of “changes that have been made since Joan’s death” but ordered the home to respond to his report, in writing, by May 5 to officially outline “details of action taken or proposed to be taken” and when.
The Riverside Rest Home, which is run by Peter Fenton Warwick and managed by his daughter Carron Cayley, according to records, was rated ‘good’ by the industry watchdog when it was last routinely inspected in February 2019.
It is said to specialise in caring for the over-65s and those with dementia and learning disabilities.
The home did not respond to a request for comment by the time of publication.
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