Death of patient who fell from Highfield House care home roof – “accidental”

A CARE home where an 87-year-old woman fell to her death from the roof has been exonerated by a coroner. Dolly Cook, who had dementia, often wandered at night at the Highfield House residential home in Newent.

But mystery still surrounds how she managed to get through a secured fire door onto the roof without breaking a ceramic security device.

At Gloucester Coroners Court, Assistant Deputy Gloucestershire Coroner Tom Osborne recorded a verdict of accidental death and said the homeowners and staff were not to blame.

He said: “The fire service was quite satisfied with the safety of fire doors at the home and whenever improvements were suggested, the owners carried them out. Therefore any criticism of the home would be unreasonable.”

The coroner apologised to her relatives Terry and Olive Young, from Worcester, for the “unacceptable” delay in holding the inquest – seven years almost to the day after she died.

Mrs Cook, who in her younger years ran a garage in Newent with her husband Tom, lived for many years in the town’s Glebe Road. She was a resident at the Highfield House residential home in the Culver Street for three years at the time of her death on October 22, 2005.

Police launched an investigation into the circumstances leading to her death after she was found on a patch of grass and rushed to hospital, where she died from multiple injuries.

Night carer Yvonne Hardiman, who still works at the home, told the inquest there were two staff on duty that night – one sleeping and one awake. She said she was in charge of 27 residents and would check on them about every two hours. At about 4am she was doing paperwork when she heard a loud thud.

Her immediate concern was for Mrs Cook and one other patient, who were both known to wander, she said. When she went to Mrs Cook’s room, it was empty.

“A fire door was partly open but I did not know it could be opened without breaking the security glass,” she said.

The inquest heard Mrs Cook suffered from dementia, and her night-time wandering had increased in frequency in the months before her death. At the time, the owner of the home was David Bailey, who has since sold it.

He said Mrs Cook was funded by county council social services and added: “There was quite an extensive care package around her needs.”

Highfield House was not registered for dementia care he said, but social services were still happy to send dementia patients there.

The hearing heard a care inspector found that the home had failed to care for Mrs Cook because it had not carried out a risk assessment to handle her wandering. But Mr Bailey said she had never previously attempted to go outside in the time she had been there, although she had been into other residents’ rooms.

The coroner, who said he was not criticising the staff or set-up, suggested dementia patients should be looked after in specialist homes.