Systemic failings by social services led to ‘inadequacies’ in care of residents at scandal-hit home

A social services department failed the residents of a scandal-hit care home where seven people died after suffering poor care, a senior council manager told an inquest.

David Street (pictured), the corporate director of social services at Caerphilly County Borough Council, accepted there were “systemic failings” in the oversight of the Brithdir nursing home.

An inquest in Newport, Gwent, is hearing evidence into the deaths of seven residents at the home in south Wales between 2003 and 2005.

Some of the elderly residents suffered from dehydration, malnourishment and pressure sores.

Mr Street told the hearing it was “quite possible” the council should have taken tougher action much earlier against Brithdir owner Dr Prana Das.

In October 2004, the council put an embargo on Brithdir for any new residential placements but this was lifted two months later. A further embargo was not imposed until December 2005 and the home closed in 2006.

He also accepted social workers had failed to carry out enough reviews of the residents whose care was funded by the council, and that from 2002 there were problems with dealing with Dr Das.

“It is clear there were difficulties engaging with Dr Das and some of his senior staff,” Mr Street said.

“There seemed to be a significant disparity between the statutory agencies’ views about the quality of care delivered and the view of Dr Das and some of his more senior managers.

“Looking back you would probably conclude the relationship with Dr Das was probably untenable at an earlier stage than it ended.”

He said at the time there would have been “intense pressure” to ensure there was enough capacity to manage an increasing demand for community-based care.

“Certainly, in some aspects of the work the department did, with the benefit of hindsight, there was some inadequacies,” he said.

“Was there perhaps too much patience shown to Dr Das in terms of him being able to deliver the improvements required? I can understand why people would jump to that conclusion.

“With the benefit of hindsight we probably should have moved in sooner. I think it was probably around the end of 2004, which stands out for me.”

Mr Street agreed it was “quite possible” that more action should have been taken and the contract cancelled rather than an embargo being put in place.

The inquest heard one Brithdir resident received just two reviews in five years.

Assistant Gwent Coroner Geraint Williams asked whether that indicated a structural or systemic failure, because the allocated social worker and their managers would have known the reviews were required but they were not carried out.

Mr Street replied: “It certainly indicates a failure. Whether that was a people or a system it is difficult to say, but you certainly wouldn’t expect someone, to use your phrase, ‘drop off the radar’ to that degree.”

Mr Williams said: “Can I suggest you are avoiding the central point I am seeking to draw from you.

“This was not an individual failing in one particular case, we have two, and the fact the system was revamped when it was recognised reviews were not being handled as they should have been, is an indication of system failings.”

Mr Street replied: “In the light of the evidence I have seen, it is a system failure.”

He was asked whether a similar scandal could happen again.

“I don’t think you can ever be 100% certain of anything but I am very, very confident that nothing of this scale could happen for this duration without being picked up and acted upon,” Mr Street replied.

“I don’t think we will ever find ourselves in a position of wholescale provider failure to the level that perhaps we saw during this period.”

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.

The hearing continues.

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