Edith Pye

1. 1. insufficient staffing for personal care leading to inadequate supervision

   “At the inquest, the care home manager gave evidence that the care home recognized that Mrs. [name redacted] was a high risk of falling or rolling from her bed, and also had a history of making unsubstantiated accusations against staff. The care home therefore required: (a) that Mrs. [name redacted] personal care should always be provided by no less than two carers; and (b) that personal care should be provided, where possible, by two female carers, and if not possible, one female carer should always be present. These”

2. 2. lack of awareness of care plan requirements

   “The carer who provided personal care to Mrs. [name redacted] on the occasion when she fell from her bed on 29.3.24 knew that he should have done so with a colleague, but would regularly do so on his own. He had never himself read Mrs. [name redacted] care plan, and it became clear that two other members of staff who provided evidence to the inquest were also unaware of some key aspects of the care plan. Furthermore, other staff were aware that he would often provide care to Mrs. [name redacted] on his own, but no-one had”

3. 3. inadequate handover documentation

   “At the inquest, I was shown a handover document which had been drafted by the home's Deputy Manager, and was told that a nurse in charge would have gone through this document with all carers at the beginning of the relevant shift. The document was meant to highlight each resident's care needs, based on their respective care plans. It did not make clear that Mrs. [name redacted] required two carers for the provision of personal care, or that at least one of those carers should be female;”

4. 4. absence of audit system for handover documents

   “There was no system in place at the time for auditing these handover documents;”

5. 5. conflict of interest and delayed disclosure

   “The Deputy Manager who had drafted this handover document, was also responsible for the care home's own internal investigation into Mrs. [name redacted] fall. That internal investigation failed to highlight the deficiencies in the handover document, and the handover document itself was not disclosed to the Coroner's Office until the final inquest hearing was underway.”

6. 6. insufficient robust safeguards to prevent repeat failures

   “I am therefore concerned that insufficiently robust measures are in place at Chandler Court Care Home to ensure that the types of failure which led to Mrs. [name redacted] death have been recognized, can be picked up on, and are not repeated in the future”

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