An 86-year-old dementia sufferer died after suffering injuries in a row with a fellow resident at a care home.
An inquest was told that the wounds suffered by former police inspector Allan Wallace were consistent with him being kicked following an altercation with a 75-year-old ex miner.
Mr Wallace died three weeks after suffering cuts and bruising to his head and ears, the hearing was told. The other resident, who was also suffering from dementia and had been identified as ‘high risk’ to care staff and other residents, was found to have been wearing steel toe capped boots during the altercation with Mr Wallace on October 2.
Mr Wallace was found with his face covered with blood and the nearby wall spattered with bloodstains a ‘foot high’.
After the incident, which was not seen by staff, Mr Wallace told a deputy manager: ‘He’s done me over.’
Mr Wallace died at Mapleford Nursing Home in Huncoat on October 22, 2015, Blackburn Coroners Court was told.
A jury ruled that Mr Wallace died from natural causes contributed to by injuries sustained as a result of the altercation.
Staff told the inquest that they had believed the other resident’s steel toe capped boots were ‘ordinary boots’.
The cause of death was recorded as bronchitis, bronchopneumonia and senile cardiac amyloidosis, but the jury ruled that the soft-tissue injuries sustained by Mr Wallace in the altercation led to an immediate decline in his general health.
Mr Wallace had been subject to a deprivation of liberty safeguarding authorisation. Blackburn Coroners Court heard how the deputy manager of Mapleford, Charlotte Lowe, found Mr Wallace sprawled on the first floor landing of the home just after 8am on October 2.
Mrs Lowe told the inquest: “His face was covered in blood, there was blood on the carpet, blood up the wall.”
She wept as she described how she gave first aid to Mr Wallace while holding his head in her lap. She said: “He just said, ‘He’s done me over.’ He couldn’t understand who it was. He just said that he wanted to go up and get him.”
Mrs Lowe told the inquest that Mr Wallace’s injuries were consistent with having been kicked.
A pathologist said he suffered cuts and bruising to his head and ears.
Mr Wallace was taken to Royal Blackburn Hospital where he was hospitalised for a week before returning to Mapleford, where he developed a respiratory infection.
His daughter Alison Wallace Wood told the inquest that he was ‘severely affected’ by the altercation.
She said: “Before the incident he could recognise us and have a conversation with us, he couldn’t afterwards and didn’t again.”
Staff did not realise that ex-miner was wearing steel toe boots
The inquest heard that two months before the altercation the other resident was identified as ‘high-risk’ to staff and residents and the care home had requested that he be relocated.
The jury’s determination also found failings with the handover procedure at Mapleford.
At the time of the altercation a staff handover period routinely took place at the home at 8am in the dining room, leaving the first floor unstaffed, the inquest heard. It was during this time that the altercation occurred between the two residents and the jury ruled that the supervision of residents was “insufficient” during the morning handover.
The other resident had arrived at the home on July 23 having been detained under the mental health act in a psychiatric unit at Burnley General Hospital.
Mapleford deputy manager Charlotte Lowe told the inquest that once he arrived, the former miner was both verbally and physically aggressive with staff and other residents, as well as ‘volatile’ and ‘unpredictable’.
Although he suffered from vascular dementia, he was able to walk freely around the home, as well as feed and dress himself.
Mrs Lowe told the inquest that she had contacted the Lancashire Care NHS Foundation Trust after two weeks to say that the home could “not meet his needs” and also sought help from the Rapid Intervention Team.
She said: “I said that we were struggling to meet his needs. That we didn’t think he was in the right place. He needed one-on-one staff level.”
Mrs Lowe told the inquest that she had asked for him to be moved within a week, and the Trust had begun looking for alternative placements.
However, by October, he was still residing at Mapleford, and staff had begun using ‘distraction’ and ‘de-escalation’ techniques.
In his summing up senior coroner Michael Singleton stated that: “Although support was sought it didn’t seem to be particularly forthcoming.”
The jury ruled at Blackburn that Mapleford established that they were “not capable of meeting his needs due to the fact that he was exhibiting challenging behaviour that could not be appropriately managed thereby placing others at risk, and additional requested external support was not provided in a “timely and appropriate manner”.
Review to be held into tragic case
A review is to be held to see what can be learned from the tragedy. A spokesman for Lancashire Care NHS Foundation Trust said: “First and foremost, we would like to express our sincere sympathy to the loved ones of Mr Wallace at this very difficult time and recognise that this is a very sad case for all families and care agencies involved.
“The Lancashire Safeguarding Adults Board has requested a review to identify learning for multi-agency working in supporting adults with mental health needs.
“In some cases, our clinicians are working with people who are very unwell and have complex needs, lack capacity and display behaviour that is unpredictable and challenging to manage.
“This can lead to difficulties and delays in trying to find suitable care home placements that are able to accommodate people with such needs.”
Mapleford Nursing Home said that ‘lessons have been learnt’ from the death of Allan Wallace and new procedures have since been put in place.
Manager Julie Hammond said: “We wish to express our deepest sorrow at the circumstances surrounding the ultimate death of Mr Wallace, of whom we were very fond.
“We have taken steps to change our handover procedures and to ensure that lessons have been learnt to prevent this occurring again. We thank the Coroner for his comments that were professional and compassionate throughout the inquest process. Our ultimate thoughts are with the family of Mr Wallace and we wish to thank them for their kindness and support during this very difficult time.”