The deaths of two vulnerable people living in the same Norfolk care home, including an elderly woman who died after she was attacked by another resident, have raised serious concerns.
The two deaths at the care home, which has not been named, were not connected, but sparked safeguarding adult reviews.
The reviews, by the Norfolk Safeguarding Adults Board (NSAB), prompted a string of recommendations.
The woman who died, referred to as Ms F, had been in the home for some years and had dementia.
She was pushed over by a male resident in December 2017, breaking her hip.
She was taken to hospital before returning, but died about three weeks later.
Her family said: "Our mother was physically fit and healthy on December 18, weighing approximately 78+kg, singing, humming, laughing, chatting and dancing, and coming to the café with us for tea and cakes.
"On December 19, she was viciously attacked, knocked to the ground and never recovered from surgery. She subsequently passed away on January 31, after several seriously painful weeks, a skeletal lady weighing approximately 50 kilos, suffering from painful bed sores."
The review said the man who pushed her, referred to as Mr Z, was admitted in June 2017, as a private resident, so statutory services had not been involved in his admission process.
The report said he started to "demonstrate challenging behaviour", including punching staff and residents.
The mental health trust's dementia intensive support team got involved in July and Mr Z was medicated. The case was closed in August, with no escalation or referral for extra support.
By the middle of December, Mr Z had punched or hit other residents at least nine times.
The report says the occasion when he pushed Ms F and she went to hospital appeared to be the fourth time he attacked her.
He was then sectioned under the Mental Health Act.
While the report's role was not to consider what caused Ms F's death, it said: "the incident and subsequent surgery seems to set in motion a chain of deterioration in Ms F's physical and emotional health."
The report said: "The most severe incidents of violence towards residents were generally reported by the home to the local authority safeguarding team.
"However, the wider context of this violence in terms of its frequency and breadth did not seem to be understood, and steps that may have been taken to more effectively manage the risk (for example considering an alternative placement; detention under the Mental Health Act) did not appear to be considered by statutory services until too late."
The home explained it did not commonly look after residents behaving violently and Mr Z's needs exceeded their capacity through much of the admission.
In the second death, the resident, referred to as Mr G, was frequently in and out of acute and psychiatric hospitals.
Mr G, who had dementia and other health conditions, was discharged from a psychiatric hospital outside of Norfolk in November 2017 and went to live at the care home.
The report said the home had "significant" difficulties giving Mr G adequate care, as he was often challenging and refused it.
The dementia intensive support team noted concerns about the care home's ability to manage him, but it was not flagged as a safeguarding referral.
The relationship between Mr G's family and care home broke down and after he had been in the home for 11 days, a paramedic was called.
The ambulance crew who admitted him to hospital were so concerned about his physical state they made a safeguarding referral, querying the possibility he had experienced abuse and neglect.
The care home disputed the concerns of the ambulance service, stating they were simply those relayed by the family.
Mr G died in hospital on November 22.
The report raised concerns about decision-making and a lack of detailed inquiry or professional curiosity in the case of Mr G.
Joan Maughan, Independent Chair of NSAB, said: "On behalf of the board, I would like to convey our condolences and thanks to both families of Ms F and Mr G for their assistance throughout this very sad time.
"The aim is to try to improve the response of services to people with similar needs in a collaborative and inclusive way.
"To address a range of the recommendations from the report, including the need for professional curiosity, the way in which challenging behaviour is assessed and the recording of safeguarding data, the board will be inviting care home providers to a learning event."
Care home providers will get training in identifying what triggers challenging behaviour for people suffering with dementia and how to manage it, along with advice and support on conducting mental health checks.
What will change?
The reviews make 21 recommendations, some of which have already been enacted.
They include:
- The mental health trust's dementia intensive support team should review its safeguarding reporting processes
- Ensure all Norfolk care homes are delivering training in applying principles of the Mental Capacity Act
- Move away from a "medication-first" approach to challenging behaviour
- Reduce out of area placements under the Mental Health Act
- Develop provision for low-secure beds for patients with neurodegenerative conditions
- Norfolk County Council's adult social care safeguarding team, in conjunction with other team, should review the processes and practice for making and responding to safeguarding referrals in Norfolk care homes
- The care home involved should improve processes for reporting incident and for clinical risk assessments
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