Care home where seven residents died would be closed quicker now, Inspectorate tells inquest

A nursing home where seven residents died after suffering poor care would have been closed much sooner had the scandal happened today, an inquest has heard.

Margaret Rooney, deputy chief inspector of the Care Inspectorate Wales, said watchdogs have much tougher powers now than nearly two decades ago.

She was giving evidence at an inquest in Newport, Gwent, into six deaths at the Brithdir nursing home (pictured) in New Tredegar, South Wales, between 2003 and 2005.

Some elderly residents suffered dehydration, malnourishment, and pressure sores.

Brithdir was owned by Dr Prana Das and was part of the Puretruce Health Care group which owned another dozen homes across South Wales.

Despite ongoing problems with Dr Das and his company since 2002, including substandard care and poor staffing levels, Brithdir was not closed until 2006.

The inquest heard that in October 2004, Caerphilly County Borough Council placed an embargo on any new residential placements but this was lifted two months later. A further embargo was not imposed until December 2005.

The inquest is looking at the deaths of former Brithdir residents Stanley James, 89, June Hamer, 71, Stanley Bradford, 76, Evelyn Jones, 87, Edith Evans, 85, and William Hickman, 71.

A hearing into the death of a seventh resident, Matthew Higgins, 86, will be held following the conclusion of the other six.

Barrister Ben Summers, representing three of the victims’ families, said: “It is staggering, I would suggest, given everything that we know about what was going on, that it took until March 2006 for the Care Inspectorate Wales to actually act in relation to Brithdir.

“I think the families would appreciate trying to understand how that could have possibly happened given that all we know.”

Ms Rooney replied: “Over the last year I have been looking at these files and I really struggled with them because through the lens I have now and the legal framework, I couldn’t even think about a home like this surviving this long.

“When I looked into the detail of the files, I could see what the barriers were for the inspectors.

“I think the problem here was that the system, within the broader system of all those things coming together – the legislation, coupled with the actions others had to take to keep people safe, coupled with there were not provisions locally – they came together and made it very difficult for Care Inspectorate Wales to take the action it may have wanted to take at an earlier date.”

Assistant Gwent coroner Geraint Williams asked Ms Rooney how Dr Das was allowed to hold the registration for Brithdir.

“It is very difficult for me to answer that question having not been there,” she said.

“From what I can see (in the documents) the inspectors thought very hard about it, and they were thorough and took a long time to register the service, and they did take advice and felt they didn’t have the grounds to refuse him.”

The coroner suggested that by October 2004, inspectors should have been taking legal action to close Brithdir.

“Do you accept that at that meeting, when Brithdir was found to be ‘guilty’ of institutional abuse and that Stanley James, June Hamer and William Hickman had died as a result of gross neglect, Care Inspectorate Wales on that date did have grounds to say there was a serious risk to the life, health and wellbeing of residents?” he asked.

Ms Rooney replied: “It is very difficult for me to answer that question because I work under the powers I have now, to the lens I have now.

“Not having the broad evidence in front of me of what would happened at that time, if you go to a magistrate for that type of action, they will have expected you to weigh up what would happen to people in the round.

“I can’t answer for what the Care Inspectorate Wales staff were considering and whether they felt they had enough evidence to warrant an immediate closure.”

Ms Rooney sent her “deepest sympathies” on behalf of Care Inspectorate Wales to the bereaved families.

“I have listened to a lot of the evidence of the last eight weeks and I am truly deeply saddened by the very upsetting evidence that I have heard about what happened at Brithdir and the circumstances of the deaths of their loved ones,” she said.

“We are very sorry they suffered harm in a place that was their home and where they should have been safe.

“I wanted to acknowledge the pain and anguish that has caused them. I know this didn’t come quick enough, I do want to reassure them the lessons have not been lost and all these changes I have talked about have come about because of the lessons learnt from these events.

“I want to assure them that should anything like this ever arise again I am really confident we do have a system to enable us to react quickly and protect people.”

The hearing continues.

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