Learning the lessons from the tragic death of Dorothy Spicer

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LESSONS have to be learned from the tragic death of an elderly woman who spent a freezing night outside the care home where she lived, a coroner has said.

Coroner Gordon Ryall was speaking after a four day inquest in the death of 84-year-old Dorothy Spicer.

Mrs Spicer, who suffered from dementia and osteoarthritis, died in January, 2010, two months after she was found extremely cold and distressed in the grounds of Whitefriars care home in St George’s Avenue, Stamford.

Speaking after the inquest jury returned a narrative verdict, Mr Ryall said: “To Mrs Spicer’s family the death of their mother in such circumstances has been a great source of sadness.

“They will never forget that for about eight hours their mother was outside in the cold.

“They trusted the care of their mother to Whitefriars Care Home.

“I have no doubt that members of staff have all been affected by her death. There were systems in place that would have prevented this incident but they were not followed.

“The need for the elderly to be cared for increases and grows year on year. Caring for the elderly is not easy and can be difficult.

“It is essential that care homes for the elderly are properly run with staff levels and systems in place.”

In its verdict, the jury said Mrs Spicer, died of “pneumonia due to decreased mobility following a bout of hypothermia and dementia”.

It said Mrs Spicer, who had lived in Godsey Lane, Market Deeping before going into Whitefriars, had been outside in freezing conditions for more than eight hours.

Paramedics were called to the home at 6.42am and she was admitted to Peterborough District Hospital. She died in Stamford Hospital on January 21, 2010, after contracting pneumonia.

A statement from the jury, read by coroner Gordon Ryall, said: “The afternoon shift and the night shift did not follow the right procedure.

“There were no forms filled out at handover and there was no head count. That evening at 8.30pm no one checked on the whereabouts of Mrs Spicer as they should.”

Mr Ryall said he would write to all those who have a right to know so action could be taken to reduce the risk of such an incident happening again.

A statement from The Orders of St John Care Trust, which runs Whitefriars, said: “The trust has always accepted that it let Mrs Spicer and her family down, for which it is sincerely and deeply sorry.

“We have already disseminated the detailed learning points arising from this incident through all of our homes. We shall reflect on the verdict delivered and consider how best to incorporate it into our existing commitment to the continuous improvement of our care services.”