Failure of care by Chelmsford care home leads to resident drowning

Mr George William Mason (deceased)
Mr George William Mason (deceased)

An inquest into the circumstances surrounding the death of Mr. George Mason, who drowned in the River Chelmer on 20th October 2013, has today found a number of failures in the quality of care and security provided at BUPA’s Admirals Reach Residential & Nursing Home in Ridgewell Avenue, Chelmsford.

Mr. Mason, who suffered from dementia, was recognised to be at risk of wandering after he made several attempts to leave the home. On 19th October, he left the unit and after walking miles to the banks of the River Chelmer near Chelmer Village Way, fell into the river and was found dead in the river the following day.

An extensive list of failures by the home were raised (see note to editors) and HM Area Coroner for Essex, Eleanor McGann, sitting at Chelmsford Coroners Court, said:

“George Mason was moved from Totham Lodge care home to Admirals Reach Nursing Home on 11.10.13. A decision had been made that he needed a place in a residential dementia nursing home with nursing input, after a brief assessment had confirmed they were able to meet his needs. The fact that he was at risk of wandering and his past history were clearly documented within a short time of his arrival.

“A Deprivation of Liberty Safeguarding application was made but not as urgent. The form was completed incorrectly with no reference to the guidelines and no training on how to complete forms.

“Mr. Mason continued to try to leave and staff used distraction techniques and a level of close monitoring. No formal arrangements were put in place.

“Visitors were given a PIN number to the door to the home. On the Saturday three senior managers were not working, the unit manager was sick, and the deputy manager was on annual leave. On that date he left the home between 7.10am and 8pm, without being seen by the staff. Sometime after that but before 20.10.13 he accidentally fell into the River Chelmer and drowned.”

Mr. Mason’s only daughter, Amanda Malin, devastated by her father’s death, attended the inquest and says: “Despite suffering from dementia my dad had a good quality of life and we enjoyed our time together. The lack of care by his home, a place we trusted would look after him, has robbed us of the opportunity to continue that time together. This was an unavoidable death and while nothing will ever bring my dad back, I hope this inquest sends a message to residential care homes that they must do everything possible to uphold the safety, care and comfort of their residents so that families are confident their loved ones are not in danger.”

The family were represented by Julie Say, partner at law firm Hodge Jones & Allen, she adds: “All too often we are hearing of care home failures. That anyone in their later years should not be afforded the respect and dignity of a safe environment to live is simply not acceptable. Those entrusted with providing that safe environment need to look at the recommendations made here today and ask themselves if they are doing all they can to ensure their residents’ safety.

“The factual evidence revealed a catalogue of errors and failures on the part of Admiral’s Reach Nursing Home that ultimately led to George Mason’s death. Two particular concerns were standards of security, and the failure to adequately observe a dementia patient who was clearly in need of close supervision due to constant wandering risk. Managing wandering risk is a basic part of dementia care. Training at Admiral’s Reach, in particular in respect of applications for Deprivation of Liberty Safeguards under the Mental Capacity Act 2005, was also wholly inadequate.”

Jim Robottom of 7 Bedford Row acted as counsel for Mrs Amanda Malin.


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