Norbury Eltandia care home resident died after neglect, coroner finds

An elderly man admitted to hospital screaming in pain with bedsores and gangrene died of heart failure brought on by neglect in a Norbury care home, an inquest found today.

Incompetent staff at Eltandia Hall in Norbury – at least one of whom still works at the home – left Will Perrin dangerously malnourished after botching his medical records, Westminster Coroner’s Court heard.

The 85-year-old was in agonizing pain from bedsores and ulcers and suffering gangrene when he was finally brought to St George’s Hospital on February 6 this year, after less than a year at the Middle Way facility, the court heard.

The former Mitcham resident, who suffered from dementia, died of a heart attack on February 26.

Yesterday an inquest found the malnutrition and pressure sores he suffered at the home contributed to his death.

Coroner Dr Shirley Radcliffe described Mr Perrin’s case as one of the worst examples of care in a nursing home she had ever seen.

She added: “This is the first case I have had to deal with where neglect is the only verdict available.”

Dr Radcliffe condemned the home’s “failure to provide basic food or nourishment” and said the nursing team that looked after the 85-year-old were “out of their depth”.

She also criticised poor communication at the home.

Eltandia home manager when Mr Perrin was a resident, Terry O’Connor, said failure to develop the appropriate care plans was behind the failures, which he described as “inexcusable”.

An investigator for the Commission for Social Care Inspection, the Government’s care home watchdog, told the inquest its last report on the home from April this year showed it was adequate and improving.

He said residents were now weighed weekly rather than monthly, which exceeded usual care home standards.

Earlier Mr O’Connor said extra resources had been poured into the home and procedures, including care plans, had been tightened up to improve standards.

He said he had begun an internal investigation into the team’s conduct months before Mr Perrin’s death.

In April independent social care expert Richard Pacitti was commissioned by Merton Council to investigate the home after alerts and complaints over care.

He rejected Southern Cross’s claim that it was just the nurses, rather than the home’s management, that should have spotted the problems.

He said: “Just saying you are reliant on the nurses to do it? I would not accept that.”

The council stopped placing residents at Eltandia Hall earlier this year after investigating the home.

After close monitoring, the council decided to resume placements in July because of improved standards.

The coroner recorded a death of natural causes, contributed to by neglect.

Family questions

William Perrin’s family said the 85-year-old’s first few days at Eltandia Hall went well – and a were a far cry from his final months, when he was taken to hospital weighing nearly half as much as he did when moving in to the home.

The 83-bed home in Middle Way, Norbury, provides care and nursing for a range of vulnerable people.

Mr Perrin became a resident in May last year, after being admitted to St George’s Hospital in Tooting the previous month.

Mr Perrin had previously been cared for at his home in Streatham Road, Mitcham, but his health was deteriorating – he suffered from dementia, as well as other serious illnesses including sickle cell disease.


Joan Perrin-Henry, Mr Perrin’s daughter, said the home made a good first impression – it seemed clean and welcoming and her father, whose dementia meant he could sometimes be difficult to care for, settled in well.

But after moving in Mr Perrin began to lose weight drastically.

The inquest heard that a team of three nurses charged with caring for Mr Perrin had been incorrectly calculating his Body Mass Index (BMI), a measurement that uses height and weight to show whether someone is clinically underweight, from his admission until the end of November.

Nutrition charts were also incomplete.

The wrong figures disguised the fact the 85-year-old’s weight had dropped from 71kg on admission to the home to 56kg by November.

It would fall to 40kg in the weeks before his death.

The inquest heard the fact that Mr Perrin was becoming dangerously thin was overlooked by the nurses and other care home staff.

The inquest heard that over the next six months, his family and visiting health workers would raise the issue of his weight – and were only told the home was aware of the problem.

Mr Perrin also developed pressure sores on his buttocks, heels and lower back, which were treated with dressings and antibiotics.

Body waste seeping in to pressure sore dressings

In December, Susan Brooker, a tissue viability nurse based at Mitcham’s Wilson Hospital, was asked to examine Mr Perrin’s sores by the home.

She found that waste discharged by the doubly incontinent 85-year-old was seeping into the dressings.

She was worried his underweight state would affect the healing of the ulcers.

She told the inquest: “The weight loss was my main concern.”

Ms Brooker told the inquest when she raised the issue of Mr Perrin’s weight with the home, staff said GPs were aware of the problem.

On January 14 this year she referred her patient to a dietician as she was concerned one had still not been called for the 85-year-old.

A gangrenous finger, which developed after a wound was treated by staff but not properly reported, also caused Mr Perrin pain.

He was admitted to St George’s Hospital on February 6 over fears he was having a sickle cell crisis – although his other health problems had also escalated.

Dr Teck Khong, a consultant at St George’s who examined Mr Perrin, told the inquest he was “emaciated” and “crying out in pain” from his sores.

He said staff were forced to carefully monitor Mr Perrin for signs of “re-feeding” – a condition where the bodies of undernourished people react badly to being fed a normal amount.

Staff also noticed the sores on his heels, buttock and lower back, some of which were now measured at ‘grade four’ – meaning tissue was exposed beneath the broken skin.

Dr Khong said staff were hopeful that the patient might eventually recover and be discharged from hospital, but he died on February 26.

Pathologist Dr Peter Wilkins, the pathologist who examined Mr Perrin’s body, said he died after heart failure suffered against a background of severe coronary disease – but that the sores could have been a factor in the 85-year-old’s death.

He said: “While not directly causing the death, their presence is likely to have resulted in a loss of protein and fluid which placed an additional stress.”

He added: “This would ‘tip over’ the already compromised heart.”

Family man

William Edston Perrin was born in Westmoreland, Jamaica, on November 22, 1923.

He trained as a carpenter before emigrating to south London in 1958.

Soon after arriving in Britain he met his future wife Elfreda Bowen, a childminder.

He worked as a joiner until his retirement, using his skills to build furniture and garden sheds.

His wife died on July 25, 1999.

Mr Perrin is survived by two daughters, a son-in-law, sister, niece and five grandchildren and great grandchildren.

His daughter Joan Perrin-Henry and her husband Ludlow Henry travelled to Britain from Georgia in the United States to attend Tuesday’s inquest.

Neglect left William Perrin “looking like a Holocaust victim”, his family said following Tuesday’s inquest.

Joan Perrin-Henry, who had flown from her home in the United States to attend the hearing, said she hoped lessons would be learnt from her father’s mistreatment.

She said: “My father cannot be helped at this point, but something should be done to ensure this does not happen to someone else’s family member.”

She added: “I just can’t imagine the kind of pain he would have been in.”

Her husband, Ludlow Henry, said his father-in-law looked “like a Holocaust victim” after the neglect.

Mrs Perrin-Henry said she could see her father had drastically lost weight when she visited him last October.

She said: “I was afraid that if made a big stink and then left some one would have taken advantage of him.”

Merton Council

Simon Williams, director for community and housing at Merton Council said: “Our condolences go out to Mr Perrin’s family.

“As soon as we were made aware of Mr Perrin’s situation we stopped using Eltandia for new admissions, we reviewed any other residents for whom we had responsibility, we demanded an improvement plan from the managers of Eltandia, and we monitored closely what changes were occurring.

“We did this in collaboration with other agencies including the local NHS. We have seen significant improvements since then.

“The council takes any reports of abuse or neglect very seriously, especially where it concerns our most vulnerable residents.

“If any members of the public have any concerns then we urge them to let us know, using our 24-hour dedicated phone line 0845 618 9762.”

Care home condolences

A spokesperson for Eltandia Hall care home said: “Once again we offer our sympathy to the family on the death of Mr Perrin. Management at the home have been working closely with Merton Council, the Commission for Social Care Inspection and Social Services.

“A comprehensive action and improvement plan, looking at each individual resident’s requirements, has been implemented and significant improvements have been and are continuing to be made in our delivery of care, which have been acknowledged buy the Care Quality Commission.

“As soon as this situation was brought to our attention we implemented full disciplinary procedures and are continuing to work rigorously following this week’s verdict.

“This will include making appropriate referrals to the Nursing and Midwifery Council.”

A statement released by Mr Perrin’s daughter’s solicitors after the inquest said: “Mr Perrin’s daughter was very satisfied with the inquiry conducted by the coroner into the death of her late father.

“She was pleased that the coroner’s verdict reflected her own thoughts on the treatment her late father received while a resident at the Eltandia home.

“She will now take some time for reflection before deciding whether to pursue the matter further through the civil courts, by way of a clinical negligence action, and we will support her should she decide to pursue such a claim.”