Concerns have been raised after a care home resident died months after being assaulted by another resident.
Francis Leech died on August 26, 2024, aged 80, months after being struck multiple times in the face by another resident at Bowood Court Care Home in Redditch.
Mr Leech lived with advanced dementia and other serious health conditions, and died at Moundsley Hall Nursing Home in King’s Norton, where he had been transferred following a lengthy hospital stay.
At an inquest, senior coroner David Reid concluded that Mr Leech died from natural causes, but said his death was contributed to by "traumatic facial injuries inflicted by a fellow care home resident and a resulting lengthy hospital admission."
In February 2024, after spending four months in hospital following the assault, Mr Leech was moved to Moundsley Hall Nursing Home.
He continued to deteriorate before his death, which the coroner said was influenced by both the injuries and the functional decline associated with his hospitalisation.
The resident who assaulted Mr Leech was also living with advanced dementia and had shown "unpredictably aggressive and violent behaviour" in the six weeks leading up to the incident.
Although these episodes had been documented in incident reports, the coroner raised concerns that the resident’s care and behavioural support plans were not updated to reflect the increased risks or to outline measures for reducing them.
Mr Reid said: "Staff at the care home did not understand the importance of updating the care plan and behavioural support plan.
"Management at the care home had not instituted a system of checking and ensuring those plans were updated.
"The internal investigation carried out by the care home after the assault on Mr Leech failed to recognise the deficiencies in those plans, or to put in place measures to ensure that those deficiencies were not repeated."
Following the inquest, Mr Reid issued a Regulation 28: Report to Prevent Future Deaths to Adept Care Homes, the company that owns and operates Bowood Court Care Home.
He stated there is a "significant risk of future deaths" unless action is taken to address the failures identified in care planning and risk management.
In response to the report, Adept Care Homes said: "The importance of reviewing and updating resident care plans and Behavioural Support Plans is regularly communicated to responsible staff from the point of joining the Home and forms part of the training delivered. During evidence it was explained that monthly audits of care plans and Behavioural Support Plans by the care manager have been introduced.
"Following the conclusion of the Inquest into Mr Leech’s death, a further instruction was issued to the home management and senior care team reaffirming the expectations in relation to the review and amendment of Behaviour Support Plans and the introduction of supporting risk assessments in reflection of lessons learnt.
"We would also note that a new home manager and care manager are now in place with oversight of the Home following the incident involving Mr Leech. In respect of incident investigations, the home acknowledges that the investigation into the incident involving Mr Leech did not identify gaps within the care plans and Behavioural Support Plans in place.
"Having reflected upon this, steps have been taken to require that an individual with dementia expertise assist in completing internal investigations where an individual involved is considered to be living with dementia. By introducing this additional expertise to the investigation process, we believe that this will allow for more in depth scrutiny of care arrangements and behaviours, and for appropriate actions to be taken.
"In addition, as advised during the Inquest, practices are now in place to ensure that spot checks are conducted on a twice weekly basis of incident and accident report completion and feedback is provided to the home as required. This is in addition to their regular in person visits to the home.
"Accordingly, the home has taken steps to review the arrangements in place for the oversight of care plans and Behavioural Support plans which are now considered to be appropriate in all the circumstances.
"I hope that this response is of assistance to the Coroner in confirming the care arrangements currently in place. I would like to conclude by expressing my sincere condolences to Mr Leech’s family for their loss."
Bowood Court Care Home have been contacted for comment.
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