Pensioner died after Smethwick care home missed checks
A pensioner who had difficulty moving and required half-hourly checks was found dead face down in bed after care home staff twice failed to visit her room due to shift pressures.
Catherine Smart, who was unable to turn herself, was discovered at 10pm at Poplars Nursing Home, in South Road, Smethwick, on May 15.
She had lived there for nearly four years and suffered from various illnesses including severe dementia and arthritis. She was found with her face in a pillow with her arm under her neck.
The inquest heard that the 75-year-old died due to loss of blood supply in the airways, compression of the neck, compounded by Alzheimer's and hypertensive and ischemic heart disease.
Giving evidence at the town's council house, the home's manager Caroline Crawford said: "She was able to shuffle. She could not walk properly. In my opinion she was medium risk. It was a comfort check to ensure staff were carrying them out. The staff should have done it. It was in the care plan."
The inquest heard that Mrs Smart was put to bed before the shift change but there was insufficient staff on duty to carry out the checks while the handover procedures were under way. As a result, two checks were missed.
Dc Aimee Gibson, of West Midlands Police' adult unit, told the hearing the matter was investigated but there was insufficient evidence to bring a criminal prosecution of wilful neglect against the home.
Giving a narrative conclusion, Black Country Assistant Coroner Mr David Urpeth said: "On balance of probabilities at 10pm on May 15, 2015, Mrs Smart was found dead face down in bed despite requiring half-hourly checks.
"She had not been checked since 8.30pm that evening. In terms of my conclusion I have not found neglect. I want to make it clear that this is because there has not been enough evidence of a causal link to the time when Mrs Smart died.
"It does not mean that I do not find the scenario appalling. I want the home to be absolutely clear that it is only because of that why I have not found neglect."
Mrs Crawford said improvements had since been made to the home's monitoring systems to prevent such a matter from happening again. She apologised to the family for the failings.
Speaking afterwards, Mrs Smart's daughter Lyn said the family was 'not satisfied with the outcome'.
Originally from Scotland, the pensioner had lived in care facilities for nine years. She had been injured in an accident while on holiday in Cyprus and her health subsequently deteriorated.
