By Dan Santy 14/03 Updated: 15/03 10:09
A DEMENTIA patient who fell out of bed, broke her arm and later died from her injury did so after her carers removed protective railings from around where she slept.
Margaret Wheeler died in hospital from kidney failure, made worse by the trauma of fracturing her arm, after falling from her bed at Clifton Court care home on August 7 last year, an inquest has heard.
The 80-year-old was blind, deaf and disorientated and had been staying at the Clifton-upon-Dunsmore home for less than a month when the accident happened.
During the inquest questions arose over the home's decision to take away the railings and replace them with a crash mat on the floor to break her fall if she tried to get out of bed.
And it emerged the removal of the railings had not been documented, nor had there been any discussion held between staff over the decision to take them away.
Miss Wheeler's brother Brian, of St Andrew's Road in Coventry, told the inquest his sister had suffered with dementia problems nearly her whole life after contracting meningitis aged just two.
He went on to say he had been informed the railings had fallen off her bed and would be replaced, with the crash mat being used only as a temporary measure.
Mr Wheeler said: "In my humble opinion Margaret's condition was such there was no way she could have got herself out of bed on her own.
"Her condition was quite pitiful really. She was very thin and she had no strength in her arms."
Care home staff giving evidence at the inquest said using the railings was a risky option in cases where vulnerable patients were disorientated and could attempt to climb over them.
But they were not able to say who chose to remove the railings or how the decision was reached because of a lack of any record of it.
Giving evidence, manager Nicola Pepper said she understood a night nurse had reported an attempt by Miss Wheeler to climb over the railings.
But this was not mentioned by the nurse in a written statement given to the coroner, and Mrs Pepper also admitted no risk assessment had been done to determine the dangers in removing the railings.
She said: "Sometimes we have to make decisions on the spot. If someone thought she had tried to climb over then that decision has to be made before any paperwork.
"I believe everything we did was in the best interests of Margaret, but the paperwork didn't catch up with our practices.
"Truly, I believe removing the rails was the best decision. I would have made the same decision over and over again.
"We have learned a lot and now have very thorough checks on bed rails and have far better systems with our checks."
Coroner Zafar Siddique recorded a verdict of accidental death and said a combination of kidney failure, a fractured arm, dehydration and ongoing dementia killed Miss Wheeler.
He added: "Good practice would have meant (removing the railings) should have been documented. Clearly there were some lapses in terms of documentation and communication.
"The documentation and communication were not recorded and, to a certain degree, were inadequate."
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