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Investigation and inquest
On 3 March 2021 I commenced an investigation and opened an inquest into the death of Margaret Dorothy MEDLICOTT. The investigation concluded at the end of the inquest on 1 August 2025.
The conclusion of the inquest was that:
“On 23.4.20 Margaret Medlicott, who lived with dementia, sustained a severe head injury after being deliberately pushed over by another resident, who also lived with dementia, at Haresbrook Park Care Home, Tenbury Wells, where she had recently been admitted. She was taken to Hereford County Hospital where, despite treatment, she continued to decline. She died in the hospital from complications of that head injury on 3.5.20. The admissions to the care home of Mrs. Medlicott, and of the resident who pushed her, were in breach of restrictions agreed by the care home with Worcestershire County Council, and once admitted there, the assessment and management of the risks which each presented both to themselves and to others was incomplete.”
Circumstances of the death
The circumstances of Mrs. Medlicott’s death are set out in the narrative conclusion above.
The published report provides this section by reference to another part of the report.
Coroner’s concerns
1) The resident whose actions caused Mrs. Medlicott’s fatal head injury had a clear and recent history of unpredictable physical aggression towards his wife. The decision to admit that resident to the care home was made by a member of senior management without the clinical qualifications to assess whether the care home could meet his care needs, and was in clear breach of a restriction agreed by the care home with Worcestershire County Council that no person was to be admitted who presented with “physically challenging behaviour”. Despite having concerns about the decision to admit him, no member of staff at the care home felt able to raise or question that decision with senior management. There is therefore a concern that staff at the care home may not understand that it is their professional duty to question such decisions, and that the care home is not providing a working environment which encourages them to do so;
2) Despite being aware of concerns about the behaviour of both Mrs. Medlicott and the other resident both before and shortly after their respective admissions to the care home, staff there failed to complete proper risk assessments and care plans addressing the risks posed by each of them to themselves and to others. Those failures were accepted, but the inquest heard no satisfactory explanation as to why they might have occurred. There is therefore concern that the staff concerned, and perhaps other staff at the care home, have not received proper training in how to carry out these important tasks.
