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Investigation and inquest
On 7 November 2017 an investigation was commenced into the death of Stephen Martin Verrall, aged 57 years. The investigation concluded at the end of the inquest on 30 September 2021. The conclusion of the inquest was a narrative conclusion finding that Stephen had fallen from the window of his first floor room of St John’s Nursing Home, Croydon and died from his injuries two days later. There had been no risk assessment for the maintenance of the windows, the window restrictor was inadequate, and there was a failure to meet health and safety guidelines of which the home should have been aware.
Circumstances of the death
See 3 above.
The published report provides this section by reference to another part of the report.
Coroner’s concerns
(1) Care Quality Commission – I was informed that CQC did not routinely check window restrictors on inspections. I was told that it was the responsibility of providers to comply with regulatory requirements in this regard. Whilst that is uncontroversial, the death in this case, and the fact that there remained unrestricted windows in August 2021 nearly four years after this death, demonstrated that checks by the regulator are required. Responsive checks after incidents are not sufficient to prevent deaths.
(2) St John’s Nursing Home – I heard that Stephen had managed to leave the home unaccompanied on several occasions. The opportunity to do so for those without capacity and without the ability to assess risk poses a risk to their lives. I was told that the reception is not manned on the weekends and there is a risk that residents may follow visitors through the door when they leave.
