A coroner has strongly criticised staff at a care home where an 89-year-old woman died after a fall, saying they "may as well not have been there".

Jacqueline Lake, the county's senior coroner, made the scathing remarks at the end of a three-day inquest into the death of Edith Alden, who was a resident at the Limes in Hellesdon, accusing the home of "a significant, serious, and gross failure”. 

Mrs Alden - known as Bunny - died 12 days after falling in the care home garden. She was found by staff on the patio floor after she left unescorted through a fire exit. 

She had been a resident of the home for four months, having initially been admitted for a week of respite care as she was assessed as being a "very high risk of falls". 

The court heard how Mrs Alden’s care plan required her to be supervised by staff while moving around the home. 

While she was not required to be under permanent 1:1 surveillance, the plan stated that she needed to be supervised while using her walking frame - which did not occur on the night of the accident. 

Eastern Daily Press: Edith Alden, known as Bunny, died at The Limes care home in Hellesdon, Norwich

The fall happened on the evening of September 13, 2021, while workers at the home were in a handover between day and night staff. 

She was taken by ambulance to hospital and died less than two weeks later on September 25. 

Mrs Lake said Mrs Alden’s death had been contributed to by neglect. 

“Mrs Alden was clearly a vulnerable person due to her age and frailty, and there was a failure to provide her with basic care or attention," she said.

"Although careers were present in the open plan areas, they were clearly not paying attention to her. They may as well not have been there.

“Mrs Alden was placed into the care of the Limes residential home. She was entrusted into their care to look after her and keep her safe. 

“Basic steps such as supervision and locking the door to the outside were not taken. I find that this is a significant, serious, and gross failure.” 

Mrs Lake went on to say that the fall, in which she sustained a serious head injury, directly led to her death. 

She added: “There was an opportunity to take steps which would have prevented her death. 

“Had she been supervised, or had the support of one carer, the evidence is that she would have been guided away from the door and action taken to keep her safe. 

“Had the door been locked, she would not have been able to open it and step outside on the patio area. 

“On this basis, I find that Mrs Alden’s death was contributed to by neglect.” 

Following the inquest, Mrs Lake said she would be issuing a Prevention of Future Deaths report with outstanding concerns.

This included better consistency with care plans and risk assessments, making sure steps are in place to mitigate risks, consistent and clear recording of documentation, and staff knowing the expected requirements of each resident.

She also said she would be writing to the Care Quality Commission (CQC) about the issue of residents at ‘very high risk of falls' being allowed in communal areas with no carer present. 

She added that there needs to be a bigger focus on preventing accidents rather than responding to them.

Finally, she cited concerns over low staffing levels, especially during night shifts. 

Evidence from the Limes said that since Mrs Alden’s death there had been a change in the management structure and extra steps had been put in place.

This included the installation of a key code on the lounge door to prevent residents from leaving without staff being aware.

Eastern Daily Press: Edith Alden, known as Bunny, died at The Limes care home in Hellesdon, Norwich

Recording a narrative conclusion, Mrs Lake said: “Mrs Alden was assessed at very high risk of falls and required supervision when mobilising outside. 

“On September 13, 2021, Mrs Alden - unnoticed and unsupervised - got up from her chair, walked through the communal area, opened an unlocked door and stepped outside. There she fell. 

“Mrs Alden suffered severe head injuries and died as a result."

Speaking after the inquest, Mrs Alden’s family said: “Now justice has been done, we can finally lay Bunny to rest and find some peace in ourselves.”

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