'Inconsistent approach to Covid guidelines' finds coroner - at care home where seven elderly residents died
Area Coroner Alison Longhorn today ruled there was no need to issue a prevention of future deaths report and was satisfied changes had been made
Last updated 17th Oct 2024
A coroner's ruled that staff actions did not directly cause the deaths of seven elderly people who died from Covid at a Devon care home.
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.
The inquest had heard one staff member thought Covid was a hoax and police found residents with isolation notices on their doors - which were left open. One of the deceased's family members had felt her sister was afraid to speak up as she thought there 'might have been repercussions on her day-to-day care'.
Chris Gilliam lost his 96 year old father Roy and now wants families to have more powers to raise concerns.
He said: "My main concern is the imbalance of power between the care home system and individual patients and their families.
"By definition, individuals in care are vulnerable and unable to protect themselves. The only way I can see of improving this is for each one to have a dedicated social worker, rather like children in care."
During the inquest, families were invited - by a coroner - to question police about why criminal charges have not been brought. One family member 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.
The Nursing and Midwifery Council has confirmed it is looking at the situation - but has not given any indication as to how active its inquiry currently is.
Area Coroner Alison Longhorn found the steps taken by the home were 'clear for staff to follow' and guidance was displayed on notices to staff.
During today's judgement the coroner outlined the various responses to concerns that some staff were not wearing masks incorrectly - including a new 'mask wearing protocol' being issued.
Ms Longhorn found the wearing of masks was not 'adhered to consistently', despite it being the 'first line of defence' against Covid.
The inquest was told staff were being tested three times a week and they were told to isolate if they tested positive - but adherence was 'inconsistent' and there was 'ineffective oversight'.
The coroner reflected on the evidence of a whistle-blower, who had alerted police, that positive staff were continuing to work and some results put down to being a 'bad batch'.
Area Coroner Alison Longhorn reflected that 'infection control measures were not followed consistently' and if they had been it was possible the measures may have prevented the 'infection becoming as widespread as it did' days later.
She reflected it was not possible to know when and how each of the deceased contracted Covid. The inquest was told the Care Quality Commission had raised concerns about things like infection control during an inspection just before the deaths. The coroner today reflected a further CQC inspection, months later, showed an number of improvements had been made - with the overall rating currently standing as 'good'.
Ms Longhorn says she was satisfied the local government and social care ombudsman could investigate any concerns raised by families - and the offence of 'wilful neglect' has now been created and so additional legislation is not required.
After the inquest concluded, Alison Shaw who lost a loved one, said she felt a sense of 'dissatisfaction'.
There's more about the evidence heard in the case here