Coroner calls for lessons to be learned following Norfolk man’s death in ‘horrific’ circumstances
A coroner has demanded lessons be learned after social services failed to check on an 82-year-old man with Parkinson's disease who was then found dead in 'horrific' circumstances.
Social services staff were supposed to check on Kenneth Mills four times a day, but they failed to do so and his son faced the 'terrible trauma' of finding his father dead and his frail mother lying in her own urine next to him.
Coroner William Armstrong is writing to Norfolk County Council raising his 'deep concern' about why the family were failed.
Bosses at County Hall have said the case has prompted a review of their processes and prompted changes to the way they work to prevent it happening again.
Mr Mills, from Caistor Lane, Caistor St Edmund, near Norwich, died from natural causes at home in September last year.
An inquest heard that Mr Mills, a former audio visual-technician, was found dead at home by his son Jeremy, slumped in his wheelchair with his wife Elizabeth lying beside her wheelchair.
It is not known exactly when Mr Mills died, but the frail and vulnerable couple, who had a care package in place which meant they were visited four times a day, had not been seen for more than three days.
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It had been arranged that the couple, who were visited by carers on the morning of Friday, September 24, last year, were meant to leave their home for respite care later that day, but they refused, much to the frustration of their sons Jeremy and Jonathan.
Social services were notified of the situation by Mr Mills' son Jeremy, who asked them to reinstate the care package which had previously been in place.
But Anthea Sherwood, a social worker at the southern locality community services team, who had assured him that it would be reinstated, told the inquest the sheer 'volume of calls' she was dealing with meant that request was never actioned.
It was only on the afternoon of Monday, September 27, 2010, when Jeremy called in to see his parents, that the full extent of the failing was discovered.
Giving evidence at the inquest, Jeremy said: 'I opened the door and was hit by a smell and shouted, 'Where are you?' Mum said they were in the kitchen. There was lots of mess on the floor and father was in his wheelchair. I said, 'What on earth are you doing there?' And she said, 'He's dead'.
'She was lying on her back on the kitchen floor in all sorts of mess.'
Mr Armstrong, who recorded a verdict that Mr Mills died as a result of natural causes, said: 'It's a matter of deep concern that no action was taken to reinstate the care arrangements on Friday, September 24, which meant that Mr and Mrs Mills, who were very, very vulnerable and aged, were left in their home with no one visiting them after 7.30am to 8am on September 24.'
Mr Armstrong said it was not possible for him to say whether Mr Mills would not have died had the care package been reinstated, but would certainly have lessened the trauma on Mr Mills' wife and sons.
He said: 'If it had happened, his sons would have been spared not just the trauma of finding their father dead, but the terrible trauma of finding him dead in such horrific circumstances and the knowledge that Mrs Mills must've suffered awfully for a period of time.'
Mr Armstrong said that although the inquest heard that procedures had been changed as a result of this case, he would use his power as a coroner to write to social services and ensure that issues concerning how calls are handled and acted upon are addressed.
'I express my deepest sympathies to Jeremy, Jonathan and Elizabeth for their sad loss. I would like them to leave this court in the knowledge that lessons will be learned from this tragedy,' he said.
Toni Scattergood, team manager of the southern locality community services team, told the inquest that procedures had since been changed to prevent this happening again. This includes the introduction of a book to record all emergency calls received in a day which must be signed off by a senior member of staff at the end of each day to ensure that nothing is missed.
Speaking after the inquest, Mr Mills' son, Jonathan, 52, a builder from Poringland, said: 'The thing that really gets me is he didn't deserve to die like that – upside down in a wheelchair slumped over the top of it in those circumstances.
'It might well have happened to him anyway, but not in that squalor.'
Harold Bodmer, director of community services at Norfolk County Council, said: 'We were deeply saddened to hear of the death of Mr Mills and very sorry that this difficult time for Mrs Mills and her sons was made more distressing.
'We have provided care to Mr and Mrs Mills for a number of years, always looking to keep them together while meeting their respective individual needs. Mr and Mrs Mills opted on the Friday not to attend the planned respite care that was due to start that day, at which point we should have reinstated their home care for the weekend. Due to the high volume of work experienced that day, this didn't happen and we apologise for that.
'Had their home care been reinstated over that weekend, it is highly unlikely that Mr Mills' death, which was of natural causes, would have been avoided. However, Mrs Mills could have been removed from this traumatic situation sooner, and we sincerely regret that she had to experience this.
'In light of this case we have reviewed our processes and have made changes to the way we work to try to prevent this happening again. All calls are now logged centrally in the respective area teams and a senior member of staff is required to sign off that all appropriate actions have been taken at the end of each day.'
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