No-one to blame for death of Norwich man who left respite care home and was knocked down on A47 at Acle
No-one was to blame for the death of a man who was knocked down on the A47 while trying to return to his home from a respite care home he was staying at, an inquest has heard.
Thomas Hodgkinson, 83, was pronounced dead on March 11 last year, after he was struck by a car on the A47 at Acle.
A postmortem was carried out, with cause of death said to be multiple injuries due to a road traffic collision, with dementia and an ischemic heart condition contributory factors.
Mr Hodgkinson, who suffered from moderate dementia, lived at Union Street, Norwich, but had been reported missing from the Herondale Respite Care Home in Acle, before he walked on to the A47 and into the path of a car on March 10 last year.
The two-day inquest which concluded in Norwich yesterday heard that Mr Hodgkinson, who also suffered from anxiety and depression, and his wife Hilda had a 'volatile relationship' which deteriorated as his illness worsened.
By March 2011 the situation, described by Mr Hodgkinson's step-daughter Margaret Jordan as a 'nightmare' had come to a head with the family, and health workers, keen Mr Hodgkinson should be put into respite care.
Although not keen Mr Hodgkinson agreed to respite care but on arriving at Herondale staff were made aware of a problem, that he might want to leave.
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Sharon Forster, manager, said she advised his step grandson Michael that it was not a secure unit but he was still keen for the stay to go ahead.
She said: 'I made it very clear to Michael that we weren't a locked unit and so we couldn't guarantee his safety.'
She called social services to pass on her serious concerns that Mr Hodgkinson might want to leave but received no call back.
But despite get concerns, she did not think Mr Hodgkinson would leave in the way he did.
She said: 'I perhaps felt that we were going to be having a conversation with him about how it would be best to stay.
He didn't necessarily want to be there maybe in a couple of days time we would be faced with a situation where he would be saying I want to go home but never felt we would be faced with a situation where he would be leaving suddenly or without a conversation.'
Mr Hodgkinson was seen walking in the corridors at about 6pm. At about 7.25pm an alarm sounded when the fire exit door was pushed open. Staff searched for Mr Hodgkinson, even driving around Acle, but he was not found.
The inquest heard that Age Uk Norfolk, the service provider at Herondale Respite Care Home, had put in place procedures following the tragedy, including improving the whole process of taking people into a home and assessing them.
Changes to the building at Herondale include fencing off the garden where a number of the fire exits lead to, upgrading fire exit alarms to ensure they can be heard in every corridor and installing doors to areas like kitchen and staff rooms which can only be accessed by staff with keyfobs.
Tim O'Mullane, head of social care for Norwich and senior manager for social service teams in Norwich, said they had also implemented new procedures for admitting people to respite care in light of the tragedy.
He said the key changes to the new policy, implemented last month, included sending providers a copy of the full assessment care and support plan. Staff must also ensure they consider mental capacity in terms of admission.
Norfolk coroner William Armstrong said he was 'absolutely clear' Mr Hodgkinson had not wandered around in a confused state but was trying to find his way home but failed to do so safely because of a combination of anxiety and his dementia.
Mr Armstrong, who commended Age UK Norfolk and Norfolk County Council for implementing policies and procedures which might lessen the likelihood of something similar happening again, said it was an 'absolute tragedy' but one which could not be foreseen by anyone.
He added: 'No individual is to blame for what happened, everyone I'm sure was doing their best.'
Recording a narrative verdict he said: 'Thomas Stuart Hodgkinson suffered from anxiety, depression and a moderate degree of dementia. On March 10 2011 at around 3.10pm he arrived at a care home for respite care arranged by social services in conjunction with his family. At around 7.25pm he left the home giving no indication of his intentions. At around 7.40pm he was accidentally struck by a car on a trunk road and subsequently died as a result of injuries sustained.'
Mr Armstrong extended his sympathies to the family, including Mrs Jordan who he said could not have done more for Mr Hodgkinson or her mum.
Speaking after the inquest Mrs Jordan said: 'This has been a very difficult time for our family and we just hope that lessons have been learned and that nothing like this ever happens again.'