By Toby Porter
The “sudden and traumatic” death of a man with learning difficulties who fell from a care home window could have been avoided, an inquest has ruled.
Stephen Verrall, was found in the car park of St John’s Nursing Home after falling from a first-floor bedroom window on October 17, 2017.
He died in hospital two days later from his injuries.
The 57-year-old had lived at the nursing home in Haling Park Road, South Croydon since 2014 as he required assistance with all aspects of daily living.
Before his death, Stephen had been able to run away from the home on two occasions in September and October 2017, the inquest heard.
Following a four day inquest last week, a jury concluded that his death could have been prevented.
A narrative verdict outlined that in the days leading up the incident, Stephen’s routine had been disrupted due to an outbreak of diarrhoea and vomiting in the home which meant his family was unable to visit.
On September 30, the jury said: “The home did not consider Stephen’s personal needs in restricting visitation, especially considering he was not unwell; other solutions could have been found.
“Having previously expressed an intent to leave through a window and attempted to abscond from the home numerous times both successfully and unsuccessfully, there were inadequate personal risk assessments to monitor the risk.
“There was also no separate risk assessment in place regarding the maintenance of the windows. The chain window restrictor was inadequate and there was a failure to meet health and safety guidelines which the home had a responsibility to be aware of.
“We believe these factors contributed to Stephen’s death, from an incident which could have been prevented.”
Samantha Harlow, Stephen’s sister, said the family are “very pleased” with the outcome as it confirm’s his death was avoidable.
She said: “St John’s Nursing Home failed to comply with health and safety regulations and failed to carry out appropriate risk assessments. The inquest also highlighted their lack of knowledge regarding appropriately administering medication.
“They failed to provide a safe environment for my brother which resulted in his death. Stephen suffered a sudden and traumatic death which should never have happened.”
Fran More from Hugh James, the law firm that represented the family, said she hopes the findings will prevent future tragedies.
In February, the care provider pleaded guilty at Croydon Magistrates’ Court to failing to provide safe care and treatment, resulting in avoidable harm to Mr Verrall while he was resident at the home.
The nursing home was fined £80,000 and ordered to pay £3,474 prosecution costs, plus a £170 victim surcharge in a prosecution brought by the Care Quality Commission (CQC).
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