Death of pensioner found under bed at Roxburgh House Care Home in Cradley Heath remains a mystery

Retired school secretary Margaret Janney was discovered under her bed at Roxburgh House Care Home on Friday, February 10, after suffering a heart attack, Black Country Coroners Court was told.

However, when she was found at about 7pm, instead of calling 999 immediately, one member of staff made a 111 call to report the death, rather than following care home guidelines.

The staff members who were present at the time then decided to move Margaret – who was on an end-of-life pathway after a recent dramatic deterioration in her health – from the floor and onto the bed, in what they claim was done to “preserve her dignity”.

But when the on call doctor attended the home, he was not told Margaret was initially found on the floor, neither were the 111 NHS Direct service, the funeral directors or her next of kin.

Janice Bowes-Yarnall, Margaret’s niece and last living relative (pictured with Margaret below), said she was informed of her aunt’s death in a brief telephone call at 11.40pm on the Friday evening, but despite many calls to the care home could get no further information for four days.

She claims the staff’s decision to move her aunt’s body was a “clearly an attempt to present a misleading picture of the circumstances in which she died”.

She said: “The questions about my aunt’s death keep going round and round in my head.

“My aunt was a dear, kind old lady – an active member of Beeches Road Methodist Church and a long-standing worker with the WRVS.

“No one should end their days in a situation like this.”

A post mortem examination confirmed Margaret died of acute left ventricular failure, due to ischemic hypertensive heart disease, and left kidney hydronephrosis.

Numerous fractures were also found on her body, but there was no evidence of haemorrhaging or any visible injuries.

Initial concerns by registered home manager Julie Jones that procedure had not been followed were compounded when a report from a whistle blower claimed Margaret had not been checked on since 2.15pm, rather than every 30 minutes – which should be the case – as she was unable to move herself in or out of bed.

The whistle blower also claimed senior staff were told to falsely complete paperwork to make it appear that Margaret had been checked through to 6.10pm.

Solicitor Richard Follis, representing the family, said: “The admitted attempt to cover up the true facts surrounding the death of a 93-year-old lady who was totally dependent on her carers is of considerable concern.

“A number of serious questions remain unanswered. How did Margaret come to be on the floor, for how long did she lie there, when did she sustain multiple rib fractures and when did she pass away?”

An internal investigation was performed by care home manager HC One which led to the suspension and dismissal of senior care worker Sammie-Jo Gardiner, who made the initial 111 call, and assistant manager at the time Caroline Bomber, who checked Margaret for a pulse before moving her onto the bed.

A further investigation by Sandwell Council’s safeguarding adults team noted several organisational failure and inaccuracies in record-keeping at the home – with the most blatant example being an entry which said Margaret had received breakfast the morning after she died.

But on the day of Margaret’s death, Ms Gardiner said there had been staff shortages, meaning they were falling behind with their paperwork and struggling to cope.

Zafar Siddique, Senior Coroner for the Black Country, said: “The exact time staff went to Margaret’s rooms is unclear, and when they entered the room Margaret was discovered under the bed.

“Checks were made to see if there was any signs of life, but Margaret had already sadly passed away. She was then placed back into her bed.

“Rather than dial 999, a 111 call was made and also the emergency buzzer wasn’t activated immediately.

“It isn’t clear how Margaret ended up on the floor.

“Whether a heart attack could have been caused as a result of a fail – alternatively – whether she had a heart attack first and somehow that led to her falling from the bed, we don’t know, that remains inconclusive.

“Despite the evidence of all care staff and the internal investigation that took place, the exact sequence of events which led to Margaret being found on the floor is still unclear.”

Giving an open conclusion to Margaret’s death, Mr Siddique concluded: “Whether it was a naturally occurring event – the heart failure leading to a fall, or the fall taking place first then due to the heart failure that led to a fall – I simply cannot say on the evidence I have.”

The court was told that improvements had been made to the record-keeping issues at Roxburgh in the time following Margaret’s death, although no follow up review has been carried out by the CQC.

Ms Jones said the home now carries out at least 12 full care plan audits a month and has introduced random twice-a-day checks to charts, among other measures to make their culture “open and transparent”.

A spokesperson for the home said: “We are deeply saddened by the death of Ms Janney and our heartfelt sympathies go out to her loved ones during this difficult time.

“As soon as this incident came to our attention, we acted immediately to notify the relevant authorities and suspend the individuals involved.

“We conducted a thorough internal investigation and, as a result, a number of staff have been dismissed.

“We have a zero tolerance approach to any behaviour which falls short of the high standards we aspire to, particularly the falsification of documentation which is so vital to the delivery of high quality care.

“We have cooperated fully with the coroner and relevant authorities to fully investigate this matter.

“We were deeply concerned by the conduct of these former staff members, which was wholly unsatisfactory and went against everything we stand for as an organisation, and the open, transparent and kind ethos we instil in our team members.

“The health, safety and wellbeing of all those we support is our number one priority, and we will fully implement the recommendations made by the coroner as we strive to provide the high quality care that residents expect and deserve.”

Mr Siddique said: “I have considered carefully the changes which have been made by the home but I have a duty to report where I have concerns.

“I’ve been given assurances about the daily checks, but despite being told improvements have been made I still require some assurances.”

Adding: “I offer my heartfelt condolences to the family for the loss of Margaret in these tragic circumstances.”