AN inquest has found that an elderly woman died of pneumonia after spending a freezing night outside a care home because staff did “not follow the right procedures”.
The jury at the inquest of Dorothy Spicer returned a narrative verdict at Stamford Town Hall today (Friday), which said the 84-year-old died of pneumonia due to decreased mobility following a bout of hypothermia and dementia.
The verdict described how Mrs Spicer was found lying in the grounds of Whitefriars Care Home in St George’s Avenue, Stamford, on November 26, 2009, at 5am. She was 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.
A statement from the jury, read by coroner Gordon Ryall, said: “The afternoon shift and the night shift [at the care home] did not follow the right procedures.
“There were no forms filled out at hand over and there was no head count.
“That evening at 8.30pm no-one checked on the whereabouts of Mrs Spicer as they should.”
Mrs Spicer’s family were present as the verdict was read out. Her daughter Jane Howard gave evidence about the deterioration of her mother’s health after the night of November 26, 2009, on Tuesday.
After the 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.”
Mr Ryall said he would write a letter which would be sent to all those who have a right to know the verdict of the inquest so that action could be taken to reduce the risk of it happening again.
Mrs Spicer was described as having a “wicked sense of humour” by her daughter Jane Howard. Mrs Spicer lived with Mrs Howard in Godsey Lane, Market Deeping, before moving to Whitefriars Care Home.
After the hearing, Mrs Howard said the family were pleased with the jury’s findings.
She said: “There are many unanswered questions but now as a family we have to draw a close.
“After almost two-and-a-half years of torment and nightmares we have got to bring it to an end. And what an end. We have won.”
She added: “The total malfunction of that home is unbelievable. We have not thought about our next steps yet.”
Mrs Spicer’s other daughter Carol Howard said: “When the death certificate has nothing on then you can’t even say how your mother died.
“The fight here, this week, was for them to say Mum died of something.
“We see she suffered that night but we will never know how much until we meet her again.
“At least the jury pointed out that everything was not done right.”
The family said they would like to thank thank their solicitor Richard Follis, the jury, coroner Gordon Ryall and Det Graham Cunningham, of Lincolnshire Police.
Whitefriars is run by the Orders of St John Care Trust, a not-for-profit organisation.
A spokesman said: “The Orders of St John Care Trust is grateful to the coroner for his thorough examination of the evidence and has taken careful note of his comments.
“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 today and consider how best to incorporate it into our existing commitment to the continuous improvement of our care services.”
During the inquest the jury were told the last time Mrs Spicer was last seen at about 8.30pm on November 25, 2009, when she was sitting in a chair in the home’s Poppy Lounge. She was not seen again until she was found outside after 5am.
At 8.52pm the alarm on a door in a neighbouring lounge was activated and carer Louise Baldwin went to check it. The door was closed but Mrs Baldwin went outside to see if anyone was there. When she searched she did not include the place where Mrs Spicer was eventually found. She went back in and reset the alarm and told no-one of the incident.
Coroner Gordon Ryall told the jury during his summing up that if the correct procedure had been followed the incident should have been reported to the care leader who would have started a headcount.
Later that evening a male resident got outside and was found and returned to the home. Mr Ryall said a headcount should have been carried out then but was not.
The company which installed the alarm systems on the home’s doors inspected the alarms on January 26, 2010, and found a door in the lounge where Mrs Spicer liked to sit was disarmed at the time she was last seen.