Eliza Simpson · Prevention of Future Deaths report

On 17th April 2015 I commenced an investigation into the death of Eliza Simpson. The investigation concluded at the end of the inquest on 19th August 2015. The conclusion of the inquest was that the medical cause of death was ischaemic heart disease due to coronary artery disease and the conclusion as to the death was Accidental Death.

Mrs Simpson left her residence Roseneath Care Home, ████████
████████ unobserved on the 2nd April 2015. It is not known how Mrs Simpson was able to leave as all doors are locked on a magnetic locking system that was fully operational at the time. Mrs Simpson ought to have been being closely monitored and should not have been able to leave the home unobserved due to the effects of dementia, she ought also to have been the subject of a Deprivation of Liberty Safeguarding order ('DOLS') and although one had previously been put in place when it expired no application to renew it was made by the management of the Roseneath Care Home. Consequently it is my conclusion that there was a failure to adequately observe Mrs Simpson and to provide appropriate, legal, safeguards to ensure she did not leave the Care Home unaccompanied. Once her absence was discovered and reported to the police, the police conducted a diligent search for Mrs Simpson but she was not located until the 6th April 2015 when her recently deceased body was found by a member of the public at a local allotment.

The Police’s search for Mrs. Simpson was hampered by the fact that no CCTV cameras were in place at the entrances to the Roseneath Care Home so it was not possible to identify the precise time she left the property and the direction she went in.

It could not be concluded that the fact Mrs Simpson was able to leave the Care Home was causative of her death.

(1) The Roseneath Care Home appeared to have no system for ensuring that when deprivation of liberty safeguarding orders expired the client was re-assessed to determine whether the need for an order persisted and, where appropriate, seeking further order. In this case the home would have had no legal authority to hold Mrs. Simpson if she had been detected attempting to leave the premises on the 2nd April 2015. The very act of assessing Mrs. Simpson and renewing an application would have served to enforce to the Care Home and its staff the risk of her absconding and may have resulted in closer observation. Although the Roseneath Care Home has now closed if such a system is not standard in Care Homes this issue may arise elsewhere.
(2) The absence of CCTV hampered the Police investigation, although this is unlikely to have contributed to Mrs. Simpson’s death this may not always be the case and did mean that a very vulnerable member of society was left wondering around on her own when she might otherwise have been found with the aid of CCTV footage.