Inquiry hears ‘unmonitored risks’ in fatal nursing home beating

Risks were not properly assessed or monitored at a care home where a woman with dementia was beaten to death by another resident, an inquest has found.

Sheila Hartman, 88, was attacked by 92-year-old Eunice Clarke at Ridgeway Lodge, near Dunstable, Bedfordshire, in October 2022.

Previous episodes of violence and aggression were recorded by employees, but the investigation found that managers were unaware and no measures were taken that could have prevented the incident.

HC-One, which runs the home, says it has made significant improvements since the incident, including increasing the number of staff.

The families of both women, who have since met, say they believe they were “completely let down” by one of the UK’s biggest healthcare providers.

The two women reportedly got along well and were seen sitting, holding hands and talking, the hearing was told.

Both had advanced dementia.

The two women lived in a specialist dementia unit on the top floor of the 61-bedroom Ridgeway Lodge.

Sheila Hartman had been there for about three years. She moved out after struggling at home alone. Before that, the great-grandmother was a keen walker and loved to knit and make things, the inquest heard.

Her son, Richard Uridge, said: “She was a loving mother and we had an idyllic childhood, but practical would be the only word I think I would use for her.”

Eunice Clarke, who moved there in May 2022, lived two doors down from Mrs. Hartman.

Mrs Clarke’s daughter Debbie described her as a kind person who loved cooking and gardening. She cared for her mother at home, but as her dementia increased, she began to wander at night and could be verbally aggressive.

Debbie Clarke told how she was “completely exhausted” when her mother moved to Ridgeway Lodge.

She said she seemed to like the change, but was confused by the other people she thought lived in her house.

There were only two staff on duty in the top floor dementia unit on the night shift ending October 2, 2022.

A third employee, who was reportedly working on both floors of the house, called in sick.

In the early hours of the morning, the two caregivers were lifting a resident who needed personal care, when they heard a commotion, the inquiry said.

The healthcare worker who arrived at the scene found Eunice Clarke screaming in the hallway. His cane had blood on it.

Sheila Hartman was found in her bedroom with serious injuries to her head and face – her room and bedding were covered in blood. She died a few hours later with her son Richard by her side.

“She looked like she had fought 10 rounds with a heavyweight boxer,” he said. “Frankly, she was beaten and bruised.”

The jury at the two-week inquest into her death, held in Ampthill in Bedfordshire, heard that Eunice Clarke had a history of fits when confused or distressed – because of her dementia.

“She went into my mother’s room, perhaps she thought my mother was an intruder in her own home,” says Mr Uridge.

“That is a consistent theme, that Eunice was not settling into the house and thought it was her own home and that all the other residents were in some way intruders.”

The inquest was told that before moving into the home, Mrs Clarke attacked a live-in carer with a cane when she believed she was also an intruder.

A document completed before Ms Clarke moved into the care home did not mention this attack, and the home manager at the time told the inquest he had no knowledge of it.

However, handover notes completed between shifts on the unit showed that in the months before Sheila Hartman’s murder, staff witnessed Ms. Clarke entering another resident’s room and destroying it, and in another case, attempting to attack a provider. take care of your walk. stick.

The jury was told that these incidents were not escalated to the home managers, reported to social services or explained to family members of any of the affected residents in the home, so there was no care plan on how to prevent the behavior from escalating.

An independent investigation commissioned by HC One later concluded that they had “enough time to make a dementia-informed care plan” for Eunice Clarke, but failed to do so.

“It is very clear that there were many missed opportunities to properly understand Eunice Clarke’s care needs,” said Mr. Uridge, “and to provide the care she needed and to manage the risk she posed to herself and those others”.

Following the conclusion of the inquest, HC One said it worked closely with the police, local authority and the Care Quality Commission (CQC) following Ms Hartman’s death.

A spokesperson said: “We have made many improvements to improve the support and care we provide to residents with complex dementia needs… strengthening our pre-admission assessment.

“We have also reviewed and strengthened how we deploy staff (and) our new digital incident management system and digital care planning software… to give us a greater understanding of risk.”

Eunice Clarke died a few months after the attack.

In a statement, his daughter Debbie told BBC News that his illness was responsible for what happened.

“It may have been my mother’s body that committed this horrible incident, but it was not my mother,” she said.

“The only thing I’m grateful for is that my mother died without knowing she had taken another person’s life.

“The pain of what happened will stay with me.”

Uridge says her family bears no ill will and believes both women were victims of failures in care. The two families supported each other before and during the inquest.

“Both families were victims of poor care,” he said.

A CQC inspection was carried out shortly after the attack on Sheila Hartman and, although it did not look specifically at the incident, it found that staff shortages were an issue.

It stated that between July and October 2022 there were times when fewer staff were on night duty “than the number the supplier defined as safe, but no action was taken on this”.

It also found “problems with the way the registered manager, provider and staff supported people living with dementia and expressing forms of distress”, adding: “Staff training, knowledge and skills in this area were limited”.

The CQC has classified the care home as “requires improvement”. It has since been inspected again and the service is now considered “good”.