Derbyshire County Council has been fined half a million pounds after an 80-year-old woman died of injuries sustained in a fall at an Eckington care home back in March 2016.
Audrey Allen suffered 12 rib fractures and a damaged lung at the Grange care home. She died of her injuries a month later.
The council, which runs the home in Eckington, was fined £500,000 in court on Monday (9 December), having previously pleaded guilty to failing to provide safe care and treatment, resulting in avoidable harm to Audrey Allen.
The court heard that Miss Allen – a midwife who ended her career as Derbyshire’s senior nursing officer for maternity – had a documented history of falls. She was also living with dementia and other complex medical issues when she was admitted to The Grange on 3 December 2015.
Miss Allen suffered several falls and loses of balance during her three-and-a-half month stay at the care home. There were numerous instances where she was described as being unexpectedly on the floor. Despite these incidents, the council, as provider of the service, failed to adequately assess and reduce the risk of her falling.
CQC brought this prosecution after Miss Allen suffered rib fractures during a fall on 25 March 2016 at The Grange. These fractures lacerated one of Miss Allen’s lungs, leading to a haemorrhage which caused her death on 16 April 2016 at Chesterfield Royal Hospital.
The court heard that Miss Allen fell while in a communal area at the home. Staff took Miss Allen to her bed. Although she reported pain in her left side no medical advice was sought.
The following morning, staff found Miss Allen unresponsive and they called for an ambulance. Paramedics were not informed that Miss Allen had suffered a fall the previous evening, nor were they advised that she reported being in pain.
Miss Allen was taken to Chesterfield Royal Hospital where X-rays identified rib fractures. She remained in hospital until her death just over three weeks later, on 16 April.
Ryan Donoghue, prosecuting, said: “Audrey Allen was known to be at high risk of falling, yet Derbyshire County Council failed to adequately assess or meet her needs.
“The council has accepted that its falls policy was not fit for purpose or properly implemented, that protective measures to reduce the risk of Miss Allen falling were not in place and that it should have referred her to a falls specialist.”
The court heard that Miss Allen had lived a full and generous life. In addition to her work as a senior midwife, Miss Allen enjoyed spending time with her family which included several nephews and nieces. She loved animals and owned west highland white terriers, which she took to dog shows.
Victim impact statements were read to the court, saying Miss Allen had cared for her parents prior to their deaths. Her own health declined after the death of her last dog, leading to her moving from her home in Chesterfield into care.
Summing up, Judge Jonathan Taaffe addressed Miss Allen’s family, who were in court, saying: “Miss Allen had the right to a comfortable end to a dignified life. She, her family and friends were totally let down. Derbyshire County Council fell far below the standards of safe care and treatment that Miss Allen should have been able to expect.”
Derbyshire County Council pleaded guilty to failing to deliver safe care and treatment at an earlier hearing at Derby Magistrates’ Court on 6 June 2019.
Rob Assall-Marsden, interim deputy chief inspector for adult social care for CQC, said: “Audrey Allen and her family had every right to expect safe care and this is why we welcome Derbyshire County Council’s guilty plea in this matter.
“This is a distressing case and our thoughts and sympathies are with Miss Allen’s family. We hope this result sends a message to other care home providers that they must ensure people’s safety at all times and manage any risks to their wellbeing.
“This was a serious failure on the part of Derbyshire County Council. As a provider of care services, it had a specific legal duty to ensure care and treatment was provided safely to Miss Allen. They failed to do this by not ensuring risks had been fully assessed, and by not implementing measures to prevent harm to Miss Allen.
“Where we find any care provider has put people using its services at serious risk of harm, we will take action to hold them to account and ensure that others can receive safe care going forward.”
Derbyshire County Council Leader Councillor Barry Lewis said: “We would like to offer our sincere condolences to Miss Allen’s family and apologise wholeheartedly for the failings that caused her death.
“In this case, our actions fell below the high standards that we expect of ourselves and we are truly sorry for what happened. “The safety and wellbeing of our residents is our number one priority and we have worked extremely hard to address the issues involved in this tragic case.
“We have implemented a number of changes to do our best to ensure this can’t happen again including:
• Reviewing and revising our Falls Policy
• Established a Quality and Improvement Board to oversee the delivery of a quality improvement plan.
• Increasing staffing in the service. • Implementing changes to our pre-admission assessments
• Compulsory falls prevention training for staff.
“Three years on we continue to build on the progress we’ve made and a recent independent inspection of the home found evidence of improvements in the recording of falls and the admission process. “We continue to work to improve our processes to ensure that we meet the high standards that people rightly expect of us and that residents are safe in our care.”