Ipswich Hospital patient, 89, died as a result of assault in toilet

Supplied Caryl MclarenSupplied
Mrs Mclaren's daughter said her mother was looking forward to returning home on the day she was assaulted

A woman died from serious injuries after she was knocked to the floor by a fellow hospital patient who had a history of violence, a coroner has concluded.

Caryl Mclaren, 89, died at Ipswich Hospital in January 2022.

An inquest heard the incident could have been prevented if the other patient, who had advanced end-stage dementia, received more supervision.

The hospital said a "wide range" of organisational changes had been made.

"It's too little too late; the steps should have been put in place while she was in there," said her daughter Loraine Moss, speaking to the BBC.

"It's so, so hard, because she should still be here."

Supplied Caryl MclarenSupplied
Ms Mclaren was still living independently and walking to local shops

Mrs Mclaren, from Holland-on-Sea in Essex, was admitted on New Year's Eve suffering with shortness of breath.

She had several health conditions but was described as "very independent" and still walked to local shops.

Mrs Mclaren was in a toilet cubicle on the day she was due to be discharged when a man forced the door open knocking her to the floor.

The grandmother suffered a fractured wrist, rib and hip and died six days later on 11 January.

Getty Images Ipswich HospitalGetty Images
The hospital said it had made a "wide range" of organisational changes

The inquest was told the man, referred to as Mr X, lacked capacity but that no formal Mental Health Act assessment was completed for him, despite having been an inpatient for nearly three months.

An adult safeguarding report found had there been "increased" staff and supervision then "the incident could have been prevented".

Staff described how security were called out due to his behaviour on five previous occasions.

He was declared fit for discharge on 29 November 2021 but staff were unable to find him a care home that would take him quickly.

Jamie Niblock/BBC Jay MossJamie Niblock/BBC
Grandson Jay Moss said there were a "catalogue of errors"
Jamie Niblock/BBC Loraine MossJamie Niblock/BBC
Loraine Moss said her mother was the most "loving, kind person, you could ever wish to meet"

Mrs Mclaren's grandson Jay Moss said after the inquest that he wanted to campaign for new legislation, to avoid elderly patients being placed in unsuitable mixed wards.

He said: "There have been a catalogue of errors made by the hospital that could have prevented this from happening and I will go as far as I need to go to make sure this doesn't happen again."

Son-in-law Mick Moss said the family held no ill-feeling towards Mr X and said: "Someone of his behaviour should have been monitored more."

Lessons learned

Assistant Suffolk coroner Dr Dan Sharpstone concluded she died of polytrauma from multiple fractures as a direct result of the assault.

He also asked the hospital to look at training regarding painkillers, after the inquest heard Mrs Mclaren was given up to five times the recommended dose of oxycodone following the assault.

Giles Thorpe, chief nurse at the East Suffolk and North Essex NHS Foundation Trust, which runs the hospital, said: "We offer our deepest sympathies and condolences to Mrs Mclaren's family at this very difficult time.

"Our own thorough investigation has led to a wide range of changes being made throughout the trust to make sure that we learn from what happened."

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