Inquest into avoidable death of resident at disgraced Blackpool care home that was fined £145,340

The four-day inquest will expect to hear evidence from health professionals and interested persons who were involved in Mary Fallon’s care, leading up to her death on 14 July 2019.

A pre-inquest review, held at Blackpool Town Hall today (29 Nov 2023), heard how the family of Mrs Fallon were keen for an inquest to resume – despite the successful prosecution of DM Care Ltd and care home manager, Rebecca Tucker by the CQC (Care Quality Commission).

Marcus Coates-Walker, the family’s barrister, explained to the court that despite the guilty pleas, there were ‘no exploratory details’ as to how Mary, 86, came about her death while she was resident at Highbury House Care Home (Ran by DM Care Limited).

DM Care Limited was fined £138,170 and the home’s manager was ordered to pay £7,170 at Blackpool Magistrates’ Court, on 21 June, 2023.

Alan Wilson, Senior Coroner for Blackpool and Fylde, concluded that although there was ‘no uncertainty’ as to the cause of Mrs Fallon’s death, the circumstances met the criteria to hold an Article 2 Inquest – as there had been a potential breach of the duty to protect the lives of those under state care.

Five members of Mary’s family were in attendance, and barrister, Lisa Judge represented the care provider via video link.

Who is likely to give evidence at the inquest?

The coroner is likely to call on Blackpool Council and the district nursing team, to provide statements, ahead of the hearing in 2024.

One of these interested persons is a district nurse who had had raised safeguarding concerns about Mrs Fallon’s pressure sores.

He will also seek statements from care assistants, and two council workers who had both attended a ‘best interest meeting’ about Mrs Fallon.

Mr Coates-Walker suggested to the court that ‘issues were raised’ to the local authority, but were not acted upon. “Had they not been ignored, what would have happened? [She could have been] moved to a different care [home]”.

When will the inquest take place?

The full inquest into Mary Fallon’s death is likely to take place at Blackpool Town Hall, some time in May or June 2024. It is expected to last four days.

How did Mary Fallon die in the care home?

Mary’s primary cause of death was multi-organ failure caused by septicaemia, pressure sores and generalised atherosclerosis.

A CQC report found that care home manager, Rebecca Tucker, had failed to ensure Mary received proper treatment, and adequate preventative pressure sore care.

She had no previous history of pressure sores when she was admitted at Highbury House Care Home in May 2017.

The registered provider failed to show governance and oversight and its preventing pressure sores policy was outdated and did not refer sufficiently to national guidance.

District nurses raised safeguarding concerns

On 5 November 2018 Mary was treated by district nurses for pressure ulcer wounds on her feet. As a result, a safeguarding alert was raised. Further twice weekly district nurse visits continued until Mary was discharged from their care on 15 April 2019.

Mary was discharged from their care on 15 April 2019.

From 23 April 2019 there were a further 44 entries in Mary’s care plan showing her pressure sores had returned. Rather than seeking treatment from the district nursing team, Rebecca Tucker instead decided to treat them herself.

On 28 June 2019, Mary was found unresponsive in bed and was taken to Blackpool Victoria Hospital. The inspection of her pressure areas revealed multiple areas of damage across her body. Pressure ulcers and deep tissue injuries were found on Mary’s heels, elbows, hip, buttock, natal cleft and toes.

She died on 14 July 2019.

How much was the care home fined?

DM Care Limited, was fined £120,000 and was ordered to pay a £170 victim surcharge and £18,000 costs to the Care Quality Commission (CQC), which brought this prosecution. Manager of the home, Rebecca Tucker, was also ordered to pay £2,000 and £5,000 costs and a victim surcharge of £170.

Tucker, 30, of Goldcrest Avenue, Farington Moss, Leyland, was said to have failed in her duty of care at Highbury House Care Home in Lytham Road, Blackpool from April to July 2021.

What did the CQC say about the care home prosecution?

Sheila Grant, CQC’s head of adult social care inspection, said:

“Mrs Fallon had the right to be kept safe while living in and receiving care from DM Care Limited, but in this case the provider, and the manager Rebecca Tucker, failed in their legal duty to protect her from being exposed to significant harm.

“The majority of care providers do an excellent job. However, when a provider puts people in its care at risk of harm, we will take action to hold them to account and to protect people.

“I hope the outcome of this prosecution reminds care providers of their duty to assess and manage all risks to ensure people are kept safe.”