Dorothy Seekings · Prevention of Future Deaths report

On 21st September 2019, I commenced an investigation into the death of Dorothy Seekings aged 87 years old. The investigation concluded at the end of the inquest on 7th July 2021. The conclusion of the inquest was a Narrative Verdict.

Mrs Seekings was resident at Clifton Court Nursing Home in Rugby.

She was a frail elderly lady who could neither speak nor walk. She was highly vulnerable.

During the night of 8th August 2019 another resident of the home entered her room.

It is not clear why he went into her room but he suffered from dementia and may have thought he was in his room which was next door.

A carer entered Mrs Seekings’s room at approximately 4.00am and discovered she was dead. Lying next to her on bed was the other resident who was fully clothed.

A post mortem examination showed she had died of blunt force injuries.

On the balance of probabilities those injuries were caused by the other resident.

He was arrested that night but was assessed as being unfit to be detained or interviewed. Subsequently he was detained under Mental Health Act. I am satisfied that he was suffering from rapidly deteriorating Vascular Dementia and on 8th August 2019 could not form the mens rea for any form of unlawful killing.

He died on 5 May 2020.

Although the events of 8th August 2019 were not reasonably predictable I record that there was ineffective promulgation of the care plan for the other resident and occasions of physical violence to care and nursing staff (but not to fellow residents) by the other resident largely around his personal care (washing, bathing), which were missed opportunities to trigger a re-assessment of his overall risk

(1) the care plans for ████████ did not record incidents where ████████ had acted aggressively to staff members including an occasion when a staff member was kicked in the mouth by ████████.
(2) the failure to raise a safeguarding alert with the local authority regarding the above incident.
(3) The staff did not appear to be aware of the contents of the care plan for ████████ or other resident