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Investigation and inquest
On 15 March 2016 an investigation was commenced into the death of Lesley Hanson. The investigation concluded at the end of the inquest held on 11 to 12 October 2017. The conclusion of the inquest was the answers to a series of questions raised by me and answered by the Jury:
In summary the Jury concluded that the arrangements in place to reduce the likelihood that Lesley had access to the stairs were inadequate for the following reasons:
• The lack of consideration given for a self-locking mechanism.
• Failure to adhere to the procedures set out in Lesley’s Service Delivery Plan, which stated that the bottom staircase should be shut at all times and Lesley was only to access the stairs when supervised.
• The stair-gate had been left open on a number of previous occasions by other residents.
The Jury concluded that the arrangements were not adequate and the failures probably contributed to Lesley’s death as she was allowed unsupervised access to the stairs.
Circumstances of the death
Lesley Hanson was a 61 year old lady who lived at The Mount, Newport Road, St Mellons. The Mount is a scheme operated by Cardiff City Council where 3 ladies lived independently in a detached house with 24 hour support and care. Lesley Hanson had severe learning disabilities from her birth and also suffered with autistic traits, epilepsy, poor stability on her feet and more recently deteriorating vision. She lacked capacity in all aspects of her life and needed constant support. She lacked the capacity to effectively communicate her needs and was extremely restricted verbally.
Lesley Hanson was known to have poor stability and stairgates were fitted to reduce the likelihood of unsupervised access. On 11 March 2017 Lesley gained access to the stairs and subsequently fell sustaining injuries which sadly led to her death.
Coroner’s concerns
(1) The evidence revealed that the care and risk assessments did not appear to consider the impact of the gate being left open by other residents, the type of stair-gate and the suitability of the locking mechanism.
(2) It was unclear from the evidence who had the responsibility for the environment and control measures to ensure residents safety at the property.
Information checked against the published report and official responses