A coroner has demanded answers from a care home over whether lessons can be learned from the death of a grandmother.
Sheila Sullivan Ross, aged 86, died two days after falling in her room at Hylton View Care Home, in Southwick, an inquest in Sunderland heard.
Senior Coroner Derek Winter said there were a number of inconsistencies in the versions of events leading up to the fall.
Home staff said Mrs Sullivan Ross fell as she tried to retrieve her nightie from a chest of drawers, while other notes stated that she slipped on the floor or that she had tried to sit down on a chair.
Mrs Sullivan Ross’s family say she told them she fell after she attempted to go to the toilet by herself despite her poor mobility, because staff had not been there to help.
She was admitted to Sunderland Royal Hospital on November 10, suffering from a pelvic fracture. The hearing heard her condition rapidly deteriorated and she died from a pelvic haematoma. She also had an underlying ischaemic heart disease.
We were in the process of taking her out of the home – but we didn’t get there quick enoughAmanda Pallas, granddaughter
The inquest heard Mrs Sullivan Ross had moved from her home in Waterlow Close, Witherwack, only weeks before her death.
Her granddaughter Amanda Pallas told the hearing: “We were in the process of taking her home. We had secured 24-hour carers. That was going to be the week after the fateful fall. We didn’t get there quick enough.”
Mrs Pallas said family members were frequently called by Mrs Sullivan Ross, on her personal mobile, asking to take her to the toilet because she could not attract the attention of staff.
Mr Winter said he was satisfied that Mrs Sullivan Ross died as a result of an accident, but that the reason she fell may never be known.
He said: “I have heard a variety of explanations as to what may have happened in that room.”
Mr Winter said he could not ascertain neglect on the part of the home because the evidential threshold had not been met. However, he said: “The purpose of an inquest is to learn lessons where lessons can be learned.”
He said he would write to the home under Coromer’s Regulation 28 – which requires the home to review areas of concern and reply within 56 days.
He added: “I have identified a number of concerns over the two days I have heard evidence.”
One concern was that a handheld alarm could not be operated while a second buzzer on the floor was plugged in. The wall buzzer was likely out of her reach.
He said there was ‘confusion’ at the home regarding risk assessments and he was also concerned about communication. He added: “The family was only made aware of the fall when Sheila’s mobile phone was answered.”