“Gross Failings” at Care Home Linked to 96-Year-Old’s Hypothermia Death

A jury inquest concluded that there were “gross failings” in management at a care home where a 96-year-old woman with dementia died from hypothermia. Joan Chapman, a resident at Coombe End Court care home in Marlborough, was discovered deceased by staff on the morning of 7 January 2022. She had exited the building after unlocking a door and venturing outside into temperatures close to freezing. A pathologist informed the Salisbury inquest that Ms. Chapman had been outdoors for a minimum of an hour prior to her death, which the jury determined was a consequence of neglect. Ms. Chapman’s relatives issued a statement, remarking, “These are difficult findings for us as a family.” In its narrative conclusion, the jury stated: “Whilst hypothermia was the primary medical cause, it was more likely contributed to by gross failings in management.” The jury further indicated that Ms. Chapman would likely have survived had she been located sooner. They affirmed, “There was a clear and direct causal link between failings and cause of death. Death was contributed to by neglect.” The Orders of St John’s Care Trust, the organization operating the care home, stated that it has subsequently implemented modifications to its procedures. During the inquest, conducted at Wiltshire and Swindon Coroner’s Court, it was revealed that Ms. Chapman initially moved into Coombe End Court’s specialist dementia unit in 2019. Testimony indicated that on the evening of 6 January 2022, an external door’s alarm was activated when a resident departed the care home. Carmina Fernandes, an agency worker, testified that she could not remember if the alarm had been reset after the door was shut. The door featured an easily operable lock that did not require a key. Due to her dementia and elevated risk of falls, Ms. Chapman was scheduled for staff checks every two hours throughout the night. Upon a staff check at 05:00 GMT on the morning of 7 January, Ms. Chapman was not found in her bed, initiating a search. The inquest heard that the overnight temperature was 2.1C. Shortly after 06:00, Ms. Fernandes located Ms. Chapman outside on the ground, dressed in thin pyjamas, and promptly re-entered the building to alert others. Paramedics responded but found Ms. Chapman “unresponsive,” and her death was confirmed at 06:24. Following the verdict, Ms. Chapman’s family read a statement indicating their need for time to assimilate the jury’s conclusions. The statement conveyed: “We have been pleased to hear the evidence.” It continued, “We hope it is a testimony to the fact that something like this will never happen again.” Kelly Edwards, the care home manager, informed the inquest that “processes in place hadn’t been followed for checks on residents and checks on doors.” She further stated, “There was a reliance on trusting staff to do what they were supposed to do.” Naomi Chipperfield, the night shift leader, testified that door alarms were inaudible in specific areas of the building, such as the smoking area or store room. She also disclosed to the inquest that she had never received an induction on security policy or policies specific to Coombe End Court, and that she was not qualified to be in charge independently. The jury concluded that the circumstances preceding Ms. Chapman’s death involved several failures, including the external door remaining unlocked, the alarm not being reactivated, a lapse in completing night security checks, and inadequate training for the night staff. Jurors additionally pointed to a failure in monitoring the door, a deficient workplace culture regarding management checks, and insufficient communication among staff on duty. The Orders of St John’s Care Trust stated its “unreserved” apology for the deficiencies highlighted during the inquest. Subsequent to Ms. Chapman’s death, the trust reported implementing changes across its care homes, including the adoption of electronic paper checks, enhanced staff training, spot checks, and an acknowledgment of the gravity of its failure. It also mentioned the installation of keypads on external doors to prevent residents from exiting the premises.