A review has found that a woman died at a Norfolk care home shortly after being violently assaulted by a fellow resident with challenging behaviour.
The review was one of two investigations into care home deaths carried out by the Norfolk Safeguarding Adults Board (NSAB). The NSAB said the cases had a number of learning themes about caring for people with challenging behaviour due to dementia.
The first investigation concerned a woman, referred to as Ms F, who was living with dementia at an unnamed care home.
In December 2017, the NSAB said Ms F was pushed over by a male resident hitting her head as she fell to the floor fracturing the neck of her femur. The man had previously exhibited violent behaviour including punching residents in the face and head.
After returning to the care home from hospital, Ms F suffered a rapid decline in her physical and emotional health. She sadly died at the care home on 31 January 2018.
The second report, concerned a man, referred to as Mr G, with challenging behaviour who was admitted to a Norfolk care home from a psychiatric hospital.
The NSAB said the care home had significant difficulties in effectively managing Mr G and providing him with adequate care. Mr G’s personal care was often refused or delivered under challenging conditions.
The Dementia Intensive Support Team (DIST) noted concerns about the home’s ability to safely manage Mr G but this was not flagged as a safeguarding referral.
Despite their concerns, the DIST proposed to discharge Mr G to the care of his GP based on an apparent improvement in his condition.
The relationship between Mr G’s family and the care home broke down over the next three days over his care.
A paramedic was called who arranged for Mr G to be readmitted to hospital following concerns for his physical health.
The ambulance crew who admitted Mr G to hospital made a safeguarding referral querying the possibility that he had experienced neglect. The care home disputed these concerns arguing that they were the ambulance team were relaying those of the family. Mr G sadly died in hospital three days later on 22 November 2017.