During the two-and-a-half years that Beryl Simcock lived at Radcliffe Manor House care home, she fell 17 times.
After the final fall, on 10 June 2021, she was admitted to hospital. She died three weeks later.
More than four years on, her daughter, Janet Cheetham, continues to pursue public accountability following an inquest which identified multiple failures in the care provided to her mother. Ms Cheetham later received £24,000 from the care home in an out-of-court settlement agreed through solicitors, but says the payment does not address the wider issues raised by the case.
Mrs Simcock moved into Radcliffe Manor House, on Main Road, Radcliffe on Trent in November 2018 for respite care. She was in the early stages of dementia, according to her family. Ms Cheetham said her mother’s early symptoms included mild memory lapses.
Family members visited regularly and initially had no concerns about the standard of care. This changed after the start of the Covid-19 pandemic, when visits were restricted.
Ms Cheetham next saw her mother in April 2021, several weeks after what she believed to be her first fall at the home. She said her mother’s face was badly bruised. Although she had been informed of that incident, she later discovered it was not the first fall.
At the time, the care home’s policy was to notify families only if a fall was considered “major”. As a result, relatives were not informed of several earlier incidents.
Mrs Simcock fell again on 30 March 2021. This was recorded as a minor fall, and the family only became aware of it after encountering a member of staff outside the home.
The final fall occurred on the evening of 9 June 2021. At around 9.25pm, a pressure mat alarm in Mrs Simcock’s room was triggered. A member of staff attended, checked her and returned her to bed. No medical assessment was sought at that time.
The following morning, at around 2.30am, Mrs Simcock was heard crying out in pain. She was taken to hospital, where doctors found she had suffered a fractured hip.
Mrs Simcock was sedated and later developed pneumonia. She died three weeks later, aged 90.
A three-day inquest into her death was held in June 2022. The coroner concluded that the care home had failed to update Mrs Simcock’s care plan to reflect her increasing risk of falling for more than a year prior to her death. The inquest found that no proper falls risk assessments had been carried out.
The coroner also found that Mrs Simcock had been assessed as being at low risk of falling, when she should have been assessed as medium risk, and that records incorrectly stated she had never fallen, including after the incident that led to her hospital admission.
The coroner described the care planning documentation as “troubling”. He said that monthly reviews appeared to contain handwritten summaries which were identical from one month to the next.
He said that care plans and risk assessments recorded no changes in Mrs Simcock’s mobility, communication, night-time needs or ability to keep herself safe throughout her time at the home.
The coroner concluded that either the reviews were not carried out and records were falsified, or that staff completing them were not competent to do so. An internal audit also failed to identify discrepancies between recorded care plans and Mrs Simcock’s actual needs.
He said that opportunities had been missed to prevent the final fall, including referrals to specialist falls services, seeking advice on mobility aids, and reassessing the risks associated with Mrs Simcock remaining in her room, where most falls occurred.
The coroner also expressed concern about the care home’s response during the inquest, stating that it appeared to minimise the seriousness of the care planning failures and questioned safeguarding findings.
He said it was unusual to see care planning and risk assessment documentation that was “so starkly misleading”, and said he remained concerned about poor communication with the family.
Nearly two years after the inquest, the care home reached a financial settlement with Ms Cheetham. She said she donated the money to charity.
She said she had not received an apology and wanted the issues raised by her mother’s death to be publicly known to protect others.
In August this year, the Care Quality Commission rated Radcliffe Manor House as ‘inadequate’ and placed it into special measures, citing concerns about resident safety, staffing levels and a lack of assurance around care quality.
A subsequent inspection in September resulted in the home being removed from special measures, though it remained rated as ‘requires improvement’ overall.
In a statement, a spokesperson for Radcliffe Manor House said the coroner had concluded that Mrs Simcock’s death was accidental, but accepted that inaccurate record keeping amounted to a technical breach of duty. They said the home had cooperated with both the coroner and the CQC and had since introduced improvements, including a fully digitised care planning system, which they said are now in place.
