Families warn 'nothing seems to have changed' after Covid care home deaths
An inquest has been taking place looking into the seven deaths - with the coroner now considering her findings before making a judgement
Last updated 4th Oct 2024
Families at an inquest into the deaths of seven elderly residents who died after contracting coronavirus while at a Devon care home have expressed their frustrations 'that nothing has changed' and lessons have not been learnt - and they are left 'without closure'.
They were today invited - by a coroner - to question police about why criminal charges have not been brought, as an investigation into what happened continues by the Nursing and Midwifery Council.
William Wilkinson, 102, Doris Lockett, 92, Roy Gilliam, 96, Jean Hartley, 81, Susan Skinner, 70, Ronald Bampfylde, 92, and Stanislawa Koch, 93, all died in March or April 2021 at the Holmesley Care Home in Sidford.
One family member today called it 'lamentable' that the situation arose in 2021 - a year after the start of the pandemic and 12 months after UK care homes were first given Covid guidance. One family member suggested he thought 'failures could have been managed at an earlier juncture' leaving 'questions from before and after'.
Another family member called for 'better protection' for care home residents - similar to the system of oversight for children in care, with a third adding that her sister was afraid to speak up as she thought there 'might have been repercussions on her day-to-day care'.
The inquest has heard that staff realised there was potentially an outbreak on the morning of March 2, but days before six positive results had been ignored and attributed to a bad batch of tests.
It has been alleged that during the Covid-19 pandemic some staff did not wear face masks or PPE, that others carried on working after testing positive for the virus, and that test results were ignored.
The inquest today heard police found residents with isolation notices on their doors - which were left open - after previously being told one worker had refused to wear a mask as they believed the virus was a conspiracy.
In 2021 Detective Sergeant Tom Hall worked as part of the local safeguarding team, which would investigate cases relating to places like care homes.
He first heard of the case after a whistleblowing email from deputy manager Jemma Turner - who cited concerns over 'management behaviour' on the Saturday - and there was a multi-agency meeting on the Monday where it was deemed to be a 'critical incident' in the force to 'recognise the impact on the residents, families and community' and ensure sufficient resources were made available.
He said: "It was clear there were measures instructed to be in place" but added 'those measures were likely not being adhered to by a couple of individuals'.
The inquest heard that 60 staff members were initially identified, with 40 then designated as 'key witnesses' and questionnaires and video interviews were conducted - as well as CCTV footage studied. The investigation then focussed on two main individuals, with police saying they were told about 'recurring themes within staff witness accounts' such as a 'failure to wear PPE, ignoring or hiding lateral flow tests and allowing- or encouraging- people to work while they had tested positive for covid'.
Alison Longhorn, area coroner for Devon, Plymouth and Torbay, was reminded the Care Quality Commission had also raised concerns the previous month over 'poor mask wearing' and police were told about a 'chaotic' atmosphere including residents with isolation notices having their doors open.
The coroner was told that the guidance was thought to be 'cruel' by some and on investigation police were told some people thought the manager 'was doing a good job in difficult circumstances' and others did not.
The inquest had details of 30 days of CCTV footage recounted as police looked to identify breaches of Covid guidelines at the time.
Tests were seized and there was a focus on 'people working when they shouldn't be' and the way they 'carried out their duties while at the home' as part of the police investigation.
The court was told Police were looking to identify if there had been a breach of Section 20 of the Criminal Justice Act 2015 which outlines the 'offence of ill treatment or neglect by a care worker'. It was decided by the Crown Prosecution Service that evidential investigations had not likely 'proved beyond reasonable doubt' any guilt.
DS Hall said he understood that the Care Quality Commission and Health and Safety Executive were better placed to investigate the situation - and there is still an ongoing Nursing and Midwifery Council investigation.
In written statements read to the hearing at County Hall in Exeter, family members questioned the basic level of care their relatives received at the home and also their concerns about staffing levels at the site which cost more than £1,000 a week.
The CQC must bring a prosecution within three years, a date which the coroner today confirmed has passed.
What has the owner of the nursing home said?
Yesterday the owner of the nursing home, where seven elderly residents died after contracting coronavirus at the height of the pandemic, told the inquest about his sorrow at learning of what may have been happening.
Will Neal said he was "disappointed" and "shocked" and found some of the allegations made about what was happening at the Holmesley Care Home in Sidford, Devon, as "absolutely unacceptable".
Mr Neal told the inquest of one occasion where Mrs Burchell had informed him she had been left with no choice but to ask a live-in care assistant, who was isolating after testing positive for Covid-19, to work because of staff shortages.
"I felt very uneasy about this, but I was not on the ground and Joanne Burchell had to make the very hard choice between the real dangers, possibly choking or falling, on one hand, and Covid exposure on the other," he said.
"With two people who were already Covid positive, she felt that seemed like the less risk.
"I was quite shell-shocked by the conversation because it was very, very difficult. She made the decision she made in the best interests and overall safety of the residents.
"I didn't like it and didn't really want to do it but it was her decision as the care professional on the ground."
Mr Neal said Mrs Burchell had told him the care worker would be working on his own and only with patients with Covid-19.
Asked about the evidence of another nurse who alleged this care worker was in fact not wearing PPE and was seen outside the room of a non-Covid-19 positive resident, Mr Neal replied: "That would be very shocking to me."
The inquest has heard that staff realised there was potentially an outbreak on the morning of March 2, but days before six positive results had been ignored and attributed to a bad batch of tests.
Mr Neal said he did not know any of this until he was told days later by Mrs Turner in a whistleblowing email.
"When I did hear about that I thought that was unthinkable," he said.
"The idea that six people would be coughing, displaying symptoms of Covid-19, and tested positive, and we just ignored it and called the GP.
"I found that hard to process. I cannot get my head around how that happened."
Mr Neal told the hearing he regretted not dismissing the nurse who was refusing to wear a mask after they had previously been told to use PPE after it was raised as a concern following a Care Quality Commission inspection the previous month.
"I feel really upset and I feel really disappointed," he said.
"The situation of not wearing a mask, when he should have been wearing a mask appropriately, is really, really disappointing to hear.
"Jemma did the one to one with him after it was identified. Maybe we should have an instant dismissal, and it is easy to say now we should have sacked him, but we had employment rules and stuff like that.
"I wished we had dismissed at that point.
"If it had been highlighted to me that he was not wearing his mask after having had that conversation I would have said he has to be suspended, and I would have been saying get rid of him.
"In terms of the six people who supposedly had a positive LFT test on March 1, if that happened that is really, really bad and I feel very disappointed about that if that has happened.
"If Jo has retained people at work when they should have gone home then that is absolutely unacceptable.
"I did assure Jemma when she whistle-blowed directly to me that I would have dealt with these matters but we were in the eye of the storm."
The inquest heard that Mrs Burchell and the nurse who refused to wear a mask were both arrested and interviewed by the police, but no further action was taken against them.
When was the alarm raised?
Jemma Turner, the nursing home's deputy manager and registered nurse, told the hearing she was telephoned in the early hours of March 2 2021 by a care worker saying there was a suspected outbreak.
"She was crying, saying, 'Jemma, the residents are poorly, I don't know what to do'," Mrs Turner said.
"I said, 'Where's the nurse?' and she said, 'He's refusing to wear a mask and he's walking around the home and he's saying that Covid is a conspiracy'.
"She said she thought he was positive too and she'd had an argument with him about doing testing.
"I told her I was on my way. I called another staff member and asked if they would come with me because I felt we possibly had an outbreak of Covid in the home."
Mrs Turner said she started testing residents on one floor of the home and all were positive.
"I thought, 'What am I going to do?'" she said.
She explained another staff member then questioned why she was testing all the residents.
"She said, 'Don't worry, we did it on Friday, the tests were a bad batch - they were all positive'," Mrs Turner said.
"I asked her what did she mean, and she said they were a bad batch. I didn't think the manager would disregard a positive test."
Three days later, Mrs Turner contacted the Care Quality Commission (CQC), Devon safeguarding and the police with her concerns about the outbreak.
"No-one wanted to help me and I felt the longer we leave it, residents could potentially die," she said.
"I think I was on the phone a good five or six hours."
The home guidelines said that if a staff member tested positive, they should be sent home, then any resident they had been in close contact with must be isolated for 14 days and all staff and residents must be tested.
The CQC had carried out two visits in the February and told the home it was not following guidelines for the use of PPE, the hearing at County Hall in Exeter was told.
Mrs Turner also alleged managers at the home would tell staff lateral flow tests (LFTs) were negative when they were in fact positive, would not show them the tests, and would allow them to work.
"A staff member messaged me, and I told her do not go to work because you are positive, go and do a PCR test," she said.
"I asked another staff member about whether he had a positive LFT and I asked him when that was done.
"I think he said either that day or the day before and I asked him if he had been to work, and he said yes and said the manager said he could work."
Mrs Turner said she had told the nurse who believed coronavirus was a conspiracy that they were required to wear PPE.
"The first time I spoke to him he expressed his view of Covid was just a conspiracy and I explained that he could have his personal view but he had to keep that to himself and while working with elderly people that are frail and at risk he had to follow the guidelines," she said.
"He told me he would. All of this was written out on a supervision form about mask wearing and daily testing and making sure he had his weekly test because there were occasions where we had to chase him up to come and do his test.
"The next time when I spoke to him, I told him he was not wearing his mask, and he needed to and that's when he said he had medical issues and he was finding it hard to breathe.
"I said he knew the rules and needed to wear the mask, and we had not had any medical exemption."
She said two days before the suspected outbreak the nurse had been complaining of feeling unwell but attributed it to tiredness and night working.
Mrs Turner said there was also a high turnover of staff at the nursing home, which she attributed to the heavy workloads and low staffing levels.
Asked for her overall impression of that time, Mrs Turner replied: "Awful. It's sad for the residents.
"They should have passed away being cared for and I felt this could have been prevented.
"I also think that if I didn't go to the police no-one would know this had potentially happened."
Louise Dalton, who worked at the home, told the hearing that if staff tested positive, they were to isolate at home for 10 days.
But she gave examples in early March 2021 of management not wanting staff to go home.
"One example of this was when the cook tested positive," she said.
"She took her test on entering the home, as we all did, and it came back as positive.
"I spoke to her, and she said that she hadn't felt well on the day before this.
"She showed the manager the positive result and said, in front of me and the other staff, words to the effect of, 'I can't be here'.
"She grabbed her coat and started to leave. The manager said words to the effect of, 'Who's going to cook dinner? Who's going to cook for the day?'
"This was to try and stop her leaving. The manager was exasperated that she would now have to try and find someone else to cook for the day."
Ms Dalton said days later during the outbreak another staff member tested positive and went to tell the manager.
"She was told that she could not go home. She was told she had done the test wrong and waited too long for the result," she said.
"Throughout the morning, she did three further tests which all came back positive.
"She was really, really cross about this as she'd taken her four positive tests but was not allowed to leave.
"I think the reasons that she wouldn't have been allowed to go home must have come from the pressures of being so short-staffed because of sickness and at that point we had no agency staff to help us out."