‘Gross neglect’ led to death of Leicester care home pensioner

A catalogue of failures which contributed to the death of an elderly care home resident who fell to the ground from a first floor landing amounted to “gross neglect”, a jury has ruled.

Marjorie Keogh died in hospital on February 7, 2010, due to injuries sustained a day earlier in the fall at Scraptoft Court Residential Home, Leicester.

The 89-year-old, who needed a mobility aid to get about, crashed through a wooden balustrade after losing her balance as she was being helped down to breakfast.

A jury at Leicester Town Hall returned a verdict of “accidental death”, but said it was contributed to by “gross neglect”.

Mrs Keogh had been a resident at the home for just over a year, having left her own home due to the onset of dementia.

The inquest heard that only one care assistant had been helping Mrs Keogh when she fell headfirst through a wooden balustrade guarding a first floor landing.

Records showed there should have been two carers, as a personal care plan stated she was at “high risk” of falling.

Family members said they had reported concerns about the stability of the staircase banisters to staff, but these were not recorded or addressed by the home.

Concerns were also raised at the inquest about staffing levels, with some employees working 13-hour shifts, and only four care staff looking after 24 residents on the morning of the accident.

A senior care manager should also have been present, but was not.

The police, Leicester City Council – as the regulatory authority for care homes in the city – and the Health and Safety Executive launched investigations into the accident.

Evidence was given that the balustrade Mrs Keogh crashed through was “entirely unsuitable”, being made of soft wood with an “impact load” of 0.36 kilonewtons (kn) per metre, when British Building Regulations required it to be 0.74kn per metre for a commercial premises.

“A structure made of hard wood compliant with the 0.74kn standard would have saved her life,” said HSE safety inspector Mark Shearon.

It also emerged during the inquest that there are no records of Scraptoft Court – built in 1997 by then and current co-owner and builder Dinesh Gokani – ever being given a building completion certificate by Leicester City Council.

Issues outstanding included the insulation of doorways and cavities to prevent the spread of fire.