Care home failings led to 96-year-old's death

There were "gross failings" in management at a care home where a 96-year-old woman with dementia died from hypothermia, a jury inquest has found.

Joan Chapman, who lived at Coombe End Court care home in Marlborough, was found dead by staff on the morning of 7 January 2022, after she unlocked a door and walked outside into near-freezing temperatures.

A pathologist told the inquest in Salisbury that she had been outside for at least an hour before she died and the jury found that her death was the result of neglect.

"These are difficult findings for us as a family," said Ms Chapman's relatives in a statement.

Returning a narrative conclusion, the jury said: "Whilst hypothermia was the primary medical cause, it was more likely contributed to by gross failings in management."

It added that if Ms Chapman had been found earlier, it is likely she would have survived.

"There was a clear and direct causal link between failings and cause of death. Death was contributed to by neglect," the jury said.

The Orders of St John's Care Trust, which runs the care home, said it had since made changes to its procedures.

The inquest, held at Wiltshire and Swindon Coroner's Court, heard Ms Chapman first moved to Coombe End Court’s specialist dementia unit in 2019.

It was told that on the evening of 6 January 2022 an alarm bell for an external door was triggered by a resident leaving the care home.

An agency worker, Carmina Fernandes, said she could not recall if the alarm had been reset after the door was closed.

The door had a lock, which was easy to open, and had no key.

Ms Chapman was meant to be checked by staff every two hours throughout the night due to her dementia and high risk of falls.

When staff checked on her at 05:00 GMT on the morning of 7 January, she was not in her bed, and a search began.

Overnight, the temperature was 2.1C, the inquest heard.

Shortly after 06:00, Ms Fernandes found Ms Chapman outside on the ground wearing her thin pyjamas, and ran back inside to raise the alarm.

Paramedics arrived, but found Ms Chapman "unresponsive" and she was confirmed dead at 06:24.

After the verdict, Ms Chapman's family read out a statement that said they would need time to process the jury's findings.

"We have been pleased to hear the evidence," the statement said.

"We hope it is a testimony to the fact that something like this will never happen again."

Care home manager, Kelly Edwards, told the inquest "processes in place hadn't been followed for checks on residents and checks on doors".

"There was a reliance on trusting staff to do what they were supposed to do," she added.

Night shift leader, Naomi Chipperfield, said there were certain parts of the building, like the smoking area or store room, where the door alarms could not be heard.

She also told the inquest that she had never had an induction on security policy, or specific policies for Coombe End Court, and that she was not suitable to be in charge on her own.

The jury concluded that failures leading up to Ms Chapman's death included the external door not being locked, the alarm not being reactivated, a failure to complete night security checks and insufficient training for the night staff.

Jurors also cited a failure to carry out monitoring of the door, a poor workplace culture for management checks and a lack of communication between staff on duty.

The Orders of St John's Care Trust said it apologises "unreservedly" for the shortcomings identified during the inquest.

Following Ms Chapman's death the trust said it had made changes to its care homes, with the introduction of electronic paper checks, improved training for staff, spot checks, and that it acknowledged the seriousness of its failure.

It also said that keypads had been introduced on external doors to stop residents leaving the building.

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