Hednesford mum of 10 died from a bleed on the brain after a care home failed to get her immediate medical attention

Seventy-nine-year-old Edna Brown suffered the fatal injury following a fall at Kingsley Cottage residential home in Hednesford last year.

A care plan prepared for Mrs Brown clearly stated that she needed medical attention after any fall – but she never got any after insisting she was fine following a fall on February 6, 2016.

She was found less than 24 hours later vomiting and fitting at the bottom of the home's stairs, before dying three days later in hospital with an irrecoverable bleed on the brain.

Medical experts were unable to say with certainty if immediate medical attention would have saved her life, which has led to the CPS not pursuing a criminal case against the requires improvement-rated home, the inquest heard.

At an inquest at Cannock Coroners Court on Tuesday morning, coroner Andrew Haigh ruled that Mrs Brown died 'from a head injury from a fall when medical attention was not immediately obtained'.

The court heard how at around 2.45am of February 6, Mrs Brown, who had only been at the home 10 days, had fallen out of bed and triggered an alarm after landing on a mat on the floor. Jacqueline Boulton, who only worked for the residential home once after the incident, visited the bedroom to find Mrs Brown sitting on the floor with her duvet around her. She then held down the alarm for her colleague on the night, Kathleen Lawton, to join her.

Ms Boulton said: "Edna kept trying to get up but I told her to stay there. On the third occasion she got up and threw the quilt off her.

"She had a very small bump over one of her eyebrows and Kate said she had to do a body check."

Giving evidence later, Ms Lawton said there were no visible signs of injury apart from the small bump. Both Ms Boulton and Ms Lawton asked Mrs Brown if she was ok and she confirmed she was, but Ms Lawton added: "There are no excuses, we should have called an ambulance."

Both Ms Boulton and Ms Lawton said they were not aware of the direction in Mrs Brown's care plan to call for medical attention if she ever had a fall due to medication she was taking.

Shirley Catchpole, the manager at the home, did know about the direction but was not called on the night of the incident, despite home policy saying the manager or deputy manager should be called if ever an incident takes place.

Both Ms Boulton and Ms Lawton informed the day staff at the home, including Maria Boote who was called to give evidence at the inquest, about the incident and they kept an eye on her throughout the day - insisting everything was fine and they noticed nothing unusual.

However, at around 9.40pm on that Saturday, just 18 hours after her fall, Mrs Brown was found at the bottom of the home's stairs fitting and vomiting. She was rushed to hospital where it was found she had a bleed on the brain. But doctors said there was nothing that could be done and she died on February 9. She left behind 10 children, 24 grandchildren and 28 great grandchildren.

In his conclusion Mr Haigh said: "Early on February 6 Edna had a fall but did not receive medical attention until later that evening when her health deteriorated." However no expert was able to say that earlier medical attention would have saved her life, although the family insist it would have.

Throughout the inquest it was told how Mrs Brown was a 'lovely lovely lady' who adored her dolls, which she referred to as her babies.

Speaking after the inquest Julie Fenn, one of Mrs Brown's 10 children, said: "She would do anything for anyone. She would ask people in the supermarket if she could carry their bags even if they were younger and twice her size."