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Failures in care and unnoticed injury led to death

failures care unnoticed injury led death

Graham Burrows (72) was born in Norfolk. He suffered from Alzheimer’s and had lived at home with his wife. In July 2017 he moved into temporary respite care and later in August that year was admitted to hospital where he remained until 5 September 2017.

He was then discharged into the care of Ashby House care home in Barchester near Milton Keynes, which claimed to specialise in the care of those with Alzheimer’s. He died there just over a month later.

Failure in duty of care

Mr Burrows had several falls while living at home with his wife. The family informed the care home of this history and he was assessed as being at high risk of further falls. It was well known that Graham would get up in the early hours and wander around the home, so a low-profile bed was provided and a sensor/crash mat were in use. Mr Burrows was also put on hourly observations. On 27 September 2017 Graham was moved to another unit within Ashby House however detailed handover notes were not provided. Crucially, the sensor/crash mat that would alert staff if Graham got up or fell out of bed were not moved with him.

At some point in the evening of 28 September or the early hours of 29 September 2017, Graham got out of bed and fell. The time is uncertain since the senor/crash mats were not transferred and the fall was not witnessed by staff. Graham was eventually found by night staff and was helped back into bed.

Injuries went unnoticed

Mr Burrows slept for most of the morning of the 29 September and at around midday a member of staff noted that his leg was at an odd angle. Paramedics were called later that afternoon. On arrival they were told by staff that it was unclear if Mr Burrows had fallen. They were also unable to confirm if he had been offered any pain relief. The ambulance took Graham to Milton Keynes hospital where it was discovered that he had in fact fractured his right hip and he underwent surgery the following day. He remained in hospital until 17 October 2017 when he was discharged back into the care home. He died on 26 October 2017. The cause of death was recorded as end stage Alzheimer’s disease, frailty and fractured neck of the femur.

Safeguarding concerns justified

A subsequent safeguarding investigation found several inconsistencies in the home’s records and concluded that the handover on 27 September was very poor. Mr Burrows was not checked at regular intervals and his case notes were incomplete (e.g. there was no record of the incident on 28/29 September). Indeed, notes purporting to be made at the time were added to his file prior to being disclosed to social services in October 2017.

Turning to Shoosmiths for help

Graham’s wife and his executors contacted Sarah Cunliffe, a solicitor specialising in care home neglect and abuse cases, for help in getting the truth about the evident failures in care Graham suffered. Shoosmiths took the case on a ‘no-win-no-fee’ basis. Sarah discovered that, whilst Graham was in hospital, it was a ward sister who had raised a safeguarding alert concerning his care at Ashby House - allegations that the subsequent investigation substantiated.

Sarah successfully negotiated a settlement of this case following proceedings being issued.

She commented:

“Compensation awards in claims such as these are never usually large, but I am pleased that we obtained what the family considered to be an appropriate sum. Finance was never their motivation however, and of course no amount of money will ever truly compensate loved ones for such a tragic, and avoidable, loss. The award does at least reimburse the expenses the executors incurred and recognises the pain and suffering Graham must have endured.”

Victoria D'Archambaud, Mr Burrows’ daughter and one of the executors of the estate who brought the claim added:

“From start to finish Sarah kept us fully updated and always answered any questions we had very quickly. Her advice in bringing our case to an end was fantastic.”



This information is for educational purposes only and does not constitute legal advice. It is recommended that specific professional advice is sought before acting on any of the information given. © Shoosmiths LLP 2024

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