Meryl Parry · Prevention of Future Deaths report

On 19th September 2014 I commenced an investigation into the death of Meryl Parry, aged 80. The investigation concluded at the end of the Inquest on 6th July 2015. The conclusion of the inquest was:

The Cause of death was:

1.a. Plastic bag asphyxia

The Conclusion of the Coroner was:

Mrs Parry was unlawfully killed

Mrs Parry had suffered from memory loss from about 2006 and in 2012 she was diagnosed as suffering from Alzheimer's disease. She lived with her husband, ████████
████████

Her abilities declined and this coincided with a substantial downturn in Mrs Parry’s own health. In August 2014 ████████ after discussion with Mrs Parry’s social worker and her GP, had decided that Mrs Parry should be accommodated in a residential home. He had spent a considerable amount of time looking for the home that he felt would be best able to accommodate his wife. One of the features of her disease was that Mrs Parry tended to wander away from home.

It was agreed that on 1st September 2014 Mrs Parry would be assessed by ████████ at the Green Lane House, Residential Home, and that she would stay there for at least a respite care whilst ████████ had hospital treatment. Mrs Parry was admitted to Green Lane House on the 1st September 2014.

On the afternoon of 1st September 2014 Mrs Parry managed to leave Green Lane House unobserved, and was found walking into Brampton. She was returned to Green Lane House and a decision was made by ████████ that it was not going to be possible to safely accommodate Mrs Parry. ████████ telephoned ████████ who was too tired to come to collect her, so she was fed, bathed, and helped into her night clothes and returned to her home address. This occurred about 8pm on 1st September.

████████ telephoned a number of residential homes, and no one was able to take his wife that night. He did not believe that Mrs Parry would be happy and able to survive living in a secure dementia unit. He was suffering from heightened tension, anxiety and stress, and he killed Mrs Parry.

(1) There appears to be no system in place whereby the managers of a residential home are required to seek advice from Social Services before discharging a resident
(2) There is therefore a serious risk that there are no appropriate arrangements in place to ensure the safety and welfare of the resident after discharge.
(3) The system for seeking advice from Social Services should apply irrespective of whether Social Services had placed the resident at the home or whether the placement had been a private one. In the latter case it is likely that a social worker will have been aware of, or had some involvement in, the placement.