Staff failed to follow rules at care home where seven people died – coroner

Measures to protect residents from Covid at a care home where seven elderly people died were not “effectively or consistently” followed by staff, a coroner has ruled.

William Wilkinson, 102, Doris Lockett, 92, Roy Gilliam, 96, Jean Hartley, 81, Susan Skinner, 70, Ronald Bampfylde, 92, and Stanislawa Koch, 93, all died in March or April 2021 after contracting coronavirus at the Holmesley Care Home in Sidford, Devon.

The deaths all came at the height of the Covid pandemic when rules were in place intended to protect residents from infection.

Alison Longhorn, area coroner for Devon, Plymouth and Torbay, told an inquest on Thursday that while there were proper processes at the home these “were not effectively or consistently followed” by all the staff working there.

A family member brought in seven red roses to represent each of the people who died at the care home, placing them on a desk in the coroner’s court.

During the inquest, it was alleged some staff did not wear face masks or PPE, that others carried on working after testing positive for the virus, and that manager Joanne Burchell ignored test results.

While the coroner acknowledged issues, she said she had not found there to be negligence at the care home.

She said: “I do not find on the balance of probabilities that the evidence demonstrated that those who worked at Holmesley more than minimally contributed to the deaths of the residents who are the subject of this inquest.”

Staff said one nurse, Christos Provistallis, refused to wear a facemask and told people he believed Covid-19 was a conspiracy. He later ended up in a hospital’s intensive care unit after contracting the virus.

Deputy manager Jemma Turner told the inquest about being telephoned by a care worker in the early hours of March 2 reporting several residents were ill.

“She was crying, saying, ‘Jemma, the residents are poorly, I don’t know what to do’,” Mrs Turner said.

“I said, ‘Where’s the nurse?’ and she said, ‘He’s refusing to wear a mask and he’s walking around the home and he’s saying that Covid is a conspiracy’.”

Three days later, Mrs Turner contacted the Care Quality Commission (CQC), Devon safeguarding and the police with her concerns about the outbreak.

The home guidelines said that if a staff member tested positive, they should be sent home, then any resident they had been in close contact with must be isolated for 14 days and all staff and residents must be tested.

Will Neal, a director of the company which owned the home, said he was “disappointed” and “shocked” and described some of the allegations made as “absolutely unacceptable”.

Staff had realised there was potentially an outbreak on the morning of March 2, but days before six positive results had been ignored, with Ms Burchell attributing it to a “bad batch” of tests.

Mr Neal said he did not know any of this until he was told days later by Mrs Turner in a whistleblowing email.

“When I did hear about that I thought that was unthinkable,” he said.

“The idea that six people would be coughing, displaying symptoms of Covid-19, and tested positive, and we just ignored it and called the GP.

“I found that hard to process. I cannot get my head around how that happened.”

Recording her conclusions, Ms Longhorn said: “Whilst the nursing home had clear policies and processes to be followed to reduce the risk of infection and spread of Covid-19, these were not effectively or consistently followed by all staff working in the home.”

She added: “We have heard much evidence that some staff at Holmesley did not effectively or consistently follow clearly defined processes regarding infection prevention and control and that their practice of not doing so potentially put that home at risk of infection.

“I would highlight that evidence heard at this inquest related to only some staff at one care home.

“I would like to thank all the families of the residents, I recognise that some of the evidence may have been upsetting or difficult to hear and I understand their frustration that no criminal prosecution will be brought.

“I want to offer all of you affected by the loss of your loved ones my condolences, I really am very sorry for your losses.”

The coroner also acknowledged recent CQC reports which indicated there had been improvements at the home.

During the inquest, family members questioned the basic level of care their relatives received at the home, their concerns about staffing levels, and the decision not to prosecute two members of staff.

Kay Soutter, a family friend of Miss Skinner, told the hearing: “We feel the change in ownership, management and constant staff changes at Holmesley at the time of the pandemic contributed to her demise.

“Were we satisfied with the care Sue received at Holmesley? Our final answer has to be no.”

Both Mrs Burchell and Mr Provistallis were arrested and interviewed on suspicion of ill-treatment or wilful neglect, but the Crown Prosecution Service decided there was not a realistic prospect of conviction.

The families criticised the decision not to prosecute.

Sally Burns, the daughter of Mr Bampfylde, told the inquest: “I am absolutely astounded by all of this.

“It’s just staggering, I am not surprised, but to hear it all condensed in just one week is just horrific.”