Coroner criticises Care Home (From Wilts and Gloucestershire Standard)

Coroner criticises Care Home

A CIRENCESTER care home has come under fire after a 94-year-old German countess in its care suffered a fall and later died.

Cotswold coroner Alan Crickmore criticised the BUPA-run Ashley House residential home in Trafalgar Road but said the homes' failings did not amount to neglect.

He recorded a verdict of accidental death on Countess Maria Mimosa von Alvensleben nee von Klitzing - known as Mimosa - who had suffered a broken leg while being transferred between two chairs.

However, he criticised the way the home circulated information about Mimosa's care plan to staff.

The inquest heard that the Countess was the daughter of Dietrich von Klitzing and his wife Mimosa, nee Baud. She was first married to Johannes von Mutzenbecher in 1935 but was divorced from him the following year.

In 1939 she married Ludolf Count von Alvensleben-Schnborn but they were divorced in 1952.

She died of broncho-pneumonia on June 10 last year at Cirencester hospital, where she had been admitted with dehydration and pneumonia-like symptoms.

It was two months before her admission that she had suffered a broken leg while transferring between two chairs at Ashley House - an event which the coroner said started the sequence that lead to her death.

The coroner said that information on how Mimosa should be cared for was not 'adequately disseminated' and that 'word-of mouth' was no substitute for a properly updated written care plan.

On the afternoon of April 28 last year care assistant Christine Wilkey and fellow assistant Sue Attwood helped to transfer Mimosa the short distance between the bath chair and her easy chair, following a bath.

Ms Wilkey told the court: "Her legs just bucked and we lowered her to the floor. We lowered her with our hands gently on her back.

"I pulled the emergency button. We said, "Are you OK?'. She said, 'Yes.' "She was just a bit frightened. We rang the emergency bell and came and checked her over while still on the floor. She was hoisted into the chair."

Nurse Mia Tanas said she attended Mimosa while she lay on the floor.

"She said that she had no pain and I couldn't see anything to indicate broken bones," Ms Tanas said. "I was surprised to learn later than she had a fracture."

Mimosa began to complain of pain to her knee on May 4, and she was given pain killers but two days later she was still in discomfort and wastaken for X-rays at Cirencester hospital where a fractured left tibia was confirmed.

She returned to the home on May 7 but was readmitted to Cirencester Hospital the following month suffering from pain in her knee and dehydration. She passed away on June 10.

Dr Simon Fox, a solicitor acting for Mimosa's daughter Helene Baines, said Mimosa's care-plan stipulated "Use hoist for transfer between bath and easy chair."

This was not done, he said but staff confirmed the accident would not have occurred if the precaution had been observed.

Coroner Alan Crickmore said: "I am satisfied that the initial fracture on April 28 was the first event in the train that led to Mimosa's death."

But Mr Crickmore made it clear that no specific action that the staff did or did not take amounted to neglect and recorded a verdict of accidental death.

"I cannot find any evidence to make me believe that there is a credible link to enable me to say that this was aggravated by neglect," he said.

"Her death was caused by an accident - the original fracture."

Following the hearing solicitor Peter Davies, representing the countess's family, said: "It was a verdict they had been led to expect but the evidence highlighted some serious failings in the management at Ashley House which they hope will now be addressed for the sake of all other residents in their care."

Alistair How, regional director of BUPA Care Homes, added: "Whilst the Coroner made it clear that the fall Countess Mimosa suffered at the home was a genuine accident we have reviewed some of the procedures to ensure that the high standards expected at the home are maintained.

"I stress that we take our responsibility for the care of our residents extremely seriously. Our thoughts are with Countess Mimosa's family at this time."