Care home staff in Tenbury Wells did not prioritise patient safety, an inquest into the death of a grandmother during the Covid pandemic hears

The inquest for a grandmother who died after she was pushed over at a care home in Tenbury Wells has concluded with the coroner ruling that she - and the resident who caused her death - should not have been placed at the home due to restrictions following critical reports from the care watchdog.

Margaret Medlicott, aged 77, died in hospital from serious head injuries on May 3, 2020 - 10 days after being deliberately pushed over by another resident at Haresbrook Park care home in Tenbury Wells operated by a Shrewsbury care firm. 

Following the three-day inquest held in Stourport, Worcestershire Senior Coroner David Reid found that the home's culture resulted that the safety of residents was not prioritised, breaching its duty of care. Both Mrs Medlicott and the male resident had advanced dementia and were placed at the site off Berrington Road at the start of the Covid 19 pandemic. 

At the time the care home was under admission restrictions, agreed with Worcestershire County Council, following critical Care Quality Commission (CQC) reports in the previous year when the council identified issues with the home.

Mrs Medlicott's daughter Karen Rosser had strongly objected to her being there due to her concerns it would not be safe for her mother’s complex needs.

Herefordshire County Council made the placement, but the coroner said Worcestershire County Council failed to tell Hereford social services about the restrictions.

He said that she should not have been admitted due to a ban on accepting residents through a pathway where patients are not fully assessed before leaving hospital known as D2A / Discharge to Assess, and a ban on admitting residents with challenging physical behaviour. In addition, the man who pushed her had previously shown physically challenging behaviour and the coroner said Haresbrook Park did not go through the proper procedures in considering his admission.

In a narrative conclusion, Mr Reid said: "On April 23, 2020 Margaret Medlicott, who lived with dementia, sustained a severe head injury after being deliberately pushed over by another resident, who also lived with dementia, at Haresbrook Park Care Home, Tenbury Wells, where she had recently been admitted. She was taken to Hereford County Hospital where, despite treatment, she continued to decline. 

"She died in the hospital from complications of that head injury on May 3, 2020. The admissions to the care home of Mrs Medlicott, and of the resident who pushed her, were in breach of restrictions agreed by the care home with Worcestershire County Council, and once admitted there, the assessment and management of the risks which each presented both to themselves and to others was incomplete."

Mr Reid added that he had ongoing concerns that further lives could be put at risk would make a prevention of future deaths report around the culture and training at Haresbrook Park.

After the hearing daughter Karen Rosser, who was represented by legal firm Leigh Day, said: "Before her dementia worsened, Margaret was known for always being so happy and popular with a wicked sense of humour."

"Our family has been left devastated that Margaret died as she did. Before she was admitted to Haresbrook Park I did all I could to protect her and make sure she was placed in a home suitable for her needs. I was repeatedly ignored when I raised concerns that the extent of my mother’s complex needs and challenging behaviour was not appreciated or being taken into account by those who should have looked after her. It was against this backdrop that she was admitted to Haresbrook Park when she should not have been, and where she was not kept safe. 

“My firm view is that systemic issues led to my mother and the man who pushed her to be placed in the home, and that Haresbrook Park appeared to be motivated by its own financial interest to accept them both when they should not have. The devastation my mother's death has had on our family will remain with us all for the rest of our lives.

"We sincerely hope that what happened to Margaret never happens again”.  

In a statement Haresbrook Park care home, operated by Shrewsbury based Capital Care Group, said: “First and foremost, our heartfelt sympathies are with the family of Mrs Medlicott. We are truly sorry for their loss.It was important to all of us that we learned from this incident, and we have taken this exceptionally seriously. In the five years since Mrs Medlicott’s death, we have made a number of important changes at our home.

"With a permanent and experienced home manager in place, we have transformed our approach to assessments, care planning, and colleague training – including a new dementia programme. We continue to work closely with the CQC and our local authority partners to embed these changes. These improvements – coupled with no longer being under the extreme and unique pressures the COVID-19 pandemic placed on care homes at the time – mean that our home is a very different place today. Our focus remains on providing safe, compassionate care to all those who make their home with us.”

Mrs Medlicott, a widow, lived in Herefordshire prior to the pandemic, had spent time living in the US and Canada with her engineer husband Edward.

No criminal charges were brought in the case.