Gate was 'open' on stairs at care home where woman, 88, fell
A HOME owner has been told by a coroner to restrict access to a flight of stairs between two floors after an 88-year-old resident fell down them and died five months later.
Mother-of-four Florence Johnson broke a hip but after being discharged from hospital, she suffered a second tumble in a different care home and fractured her other hip.
She died of a clot on the lung as immobility set in following the accidents.
An inquest heard yesterday how just 10 days before the first accident at the Ravenswood residential home in The Avenue, Kidsgrove, the retired school dinner lady was assessed as being at high risk of a fall because of her dementia – and a wooden gate at the base of the stairs should have been bolted at all times.
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But when staff found her collapsed at the foot of the 11-step flight on January 15, it was open.
After hearing evidence of how other homes had locked and alarmed gates, North Staffordshire Coroner Ian Smith told owner Jasbir Johal: "While there were no witnesses to the fall the open gate suggests she may have fallen down part or all of the staircase.
"I recommend you give serious consideration to reducing access to these stairs and consider implementing the same methods used at other homes to prevent residents going up and down them."
After Mr Johal admitted no changes had been made to the gates since the accident, the coroner suggested he adopt the coded lock system used at the Guardian Care nursing home in Trentham where Mrs Johnson suffered her second fall on March 31 as she was trying to become more mobile.
Following a hospital operation for that fracture she was discharged to Abbeywell Court home in Chesterton where she died on June 10.
Mr Johal said: "Mrs Johnson had been with us since 2009 and was pretty mobile although suffering dementia. The gate was capable of being opened by some residents but Mrs Johnson had never been seen climbing the stairs so how it happened we do not know.
"We could put a padlock on the bolt but I don't think the fire service would agree to that if they have to evacuate the residents.
"We have done nothing since the accident but we will now take some steps."
Social worker Oma Persaud who led an investigation said at the time of Mrs Johnson's fall, three of the home's seven staff had been attending to another resident so no-one had seen what happened.
The Care Quality Commission had looked into it and while no suggestions about the gate were made, the home had made changes in care procedures it had recommended.
She said: "Other homes have gates locked and alarmed. It is not possible on those just to draw back a bolt."
Recording an accidental death verdict, Mr Smith said: "There was a direct correlation between the falls and her reduction in mobility."
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