A SERIES of safety checks were missed on the night an elderly woman was found cold and distressed in the grounds of the care home where she lived, an inquest heard.
Dorothy Spicer, 84, was found lying in the garden of Whitefriars Care Home in St George’s Avenue, Stamford at about 5.50am on November 26, 2009.
She was admitted to Peterborough District Hospital and died of pneumonia two months later after being transferred to Stamford Hospital.
At an inquest into her death at Stamford Town Hall today (Wednesday) a jury heard Mrs Spicer, who suffered from dementia and osteoarthritis, had last been seen by care staff at about 8.30pm the previous evening.
The jury heard from care assistant Louise Baldwin, who worked the afternoon shift at Whitefriars on November 25. Mrs Baldwin said she had found one of the external doors in one of the home’s lounges off its latch while making her rounds.
Computer records showed the door had triggered an alarm at 8.52pm, which was reset at 9.19pm.
Mrs Baldwin said: “I went to the door, I can’t remember whether it was open or shut. I went outside. It was pitch black. I walked round to another lounge but did not see anybody then, so came back in and re-armed the door alarm.”
Mrs Baldwin said she could not remember what she did next and did not know if she told her supervisor. She said she could not remember if a head count of residents had been done after she shut the door.
Mrs Baldwin also told the jury that the door alarms were linked to pagers but on the night Mrs Spicer was found outside she was not sure any of the pagers were in use.
She added: “We were supposed to have one but they were always broken or had got lost. If you didn’t have one it was hard work.”
Mrs Baldwin was asked if she should have told a manager she found the door open. She said: “I didn’t but I should have done, I suppose. I couldn’t see anything or anybody outside. I came back in and thought maybe the door alarm was faulty or someone had pushed the door and walked away from it.
“I probably would have had the opportunity to say something.”
The jury also heard from care leader Jennifer Jameson, who was in charge of the main section of Whitefriars on the afternoon of November 25. The house is split into a main section of 36 beds and a secure dementia unit of 20 beds.
Mrs Jameson said the day had been especially busy as only three carers were on shift instead of four and fire safety training had been taking place.
She said she last saw Mrs Spicer sitting in her favourite chair in the home’s Poppy lounge. Mrs Spicer had been watching the fire training and would normally have been put to bed at about 9pm.
Mrs Jameson said the usual handover documents had not been filled in by the carers on duty so she was able to give only some details to the night shift when they took over at 9.30pm. She also said the night shift was concerned about the lack of pagers.
Janet Bagley was the night shift carer who found Mrs Spicer outside on the morning of November 26. She was one of four carers working that night, two in the main house and two in the dementia unit.
Mrs Bagley told the jury that earlier that night another resident had opened a door and set off an alarm.
She found the resident walking outside and brought him back in before resetting the alarm. She said she would normally have made sure all the residents were in the home but on that night the other carer covering the main house was getting medication training and she had other things to do.
Mrs Bagley said: “I was on my own for a big part of my shift. I was doing the job of many people. I’m only a human being.”
Mrs Bagley realised Mrs Spicer was not in her room at about 5am. The bed had not been slept in and the light was on.
Mrs Bagley said she checked all the rooms in the home with the help of the rest of the night staff. She then checked outside the home and found Mrs Spicer outside lying on the grass.
The jury heard the 84-year-old was moaning and did not respond to questions. Mrs Bagley said she and two other carers got Mrs Spicer into a wheelchair and put a blanket on her before taking her back to her room.
Two carers took Mrs Spicer’s wet clothes off while Mrs Bagley called an ambulance and the home manager, Agnes Grummit.
The jury then heard from carer Glynis Berry, who was with Mrs Bagley when she found Mrs Spicer’s room was empty.
Mrs Berry said she had been trained to do a head count after a resident was found outside. She said: “When a door has been opened you don’t know if someone is outside or if someone has come in. You don’t know if more than one person has gone out.”
Finally the jury heard from Carol Lindley, one of the paramedics who attended the scene.
She said the ambulance station, which is next to Whitefriars, received a call at 6.42am saying a resident had had a fall.
She said: “When I got there the lady was in her bed. She was wearing a nightie and was under a duvet. I thought it was strange she was in bed when we were responding to a fall.
“It was hard to get information about what had happened from the staff. Eventually a staff member said they had found her outside and she could have been there since at least 9.30pm.”
The inquest will continue tomorrow (Thursday). Whitefriars manager Agnes Grummit is expected to give evidence.