NEGLECT DEATHS AT SCANDAL CARE HOME
ELDERLY RESIDENTS ‘DEHUMANISED’ AT HOME RUN BY DISGRACED GP, INQUEST FINDS
A CORONER has criticised the care given to residents who died at a scandalhit nursing home as he highlighted a withering catalogue of failings – accusing managers of “dehumanising” and “warehousing” the elderly.
Assistant Gwent Coroner Geraint Williams yesterday said the deaths of five residents at the Brithdir nursing home in New Tredegar were contributed to by neglect.
He accused the owners and staff at the home of a “gross betrayal of the trust” placed in them by families of the residents by keeping them in the dark over the poor standards of care.
Mr Williams recorded narrative conclusions for June Hamer, 71, Stanley Bradford, 76, Edith Evans, 85, Evelyn Jones, 87, and William Hickman, 71. He said Stanley James, 89, died of natural causes.
They all died between 2003 and 2005 and suffered dehydration, malnourishment and pressure sores on their bodies.
“The view of Margaret Moody, the nursing expert, and Professor Malcolm Hodkinson, the consultant geriatrician, was that the attitude of the staff at Brithdir was that residents were being ‘warehoused,’” Mr Williams said.
“They explained this as a situation where the residents were simply kept and were being fed and watered with the bare minimum being done and then the staff going home.
“I accept without hesitation that description of the philosophy.
“What is worse, in my judgment, is that even the feeding and watering, to use Prof Hodkinson’s phrase, was inadequate given that some of the residents were admitted into hospital suffering from dehydration and malnutrition, and that the bare minimum was resolutely below any acceptable standard.
“Such philosophy I find led inextricably to a neglectful and abuseful attitude on the part of many of the staff at Brithdir, which is clearly evidenced by the practice authorised and sanctioned by Peter Smith when he was the manager of changing the incontinence pads of residents in the lounge in the presence of other staff.
“He justified that practice on the basis that as the residents were suffering from dementia, they would not know what was happening to them.
“That practice I consider was one by which the residents were dehumanised and is perhaps the lowest point in the story of the Brithdir nursing home.
“I have no hesitation in confirming as an unequivocal fact all these matters contributed significantly to the deaths of Stanley James, Judith Hamer, William Hickman, Stanley Bradford, Edith Evans and Evelyn Jones.”
Residents were often unkempt and dirty, care plans would be ignored, documents falsified and residents would be humiliated by staff.
One former staff member said she saw a care worker draw a moustache with a permanent marker on the face of a female resident.
During the inquest, several Brithdir staff apologised for the “shocking lack of care”, which was “bordering on being negligent”.
Others said there was a “systematic failure of the system” at Brithdir, with staffing levels “dire” and carers having to provide their own personal protective equipment (PPE).
Brithdir was part of a group of 24 care homes owned by local GP Dr Prana Das and his Puretruce Health Care company.
Dr Das had been the subject of complaints about his homes dating back to the mid-1990s and there had been a long history of involvement with the authorities.
Temporary embargoes on new residents were placed on Brithdir, regular inspections were carried out and improvements notices issued but it was not until 2006 the home finally closed.
Dr Das was known to be “very rude and offensive” with social care inspectors and would often launch legal challenges to decisions of regulators.
Social workers also failed to carry out regular assessment of the residents being funded by Caerphilly County Borough Council.
Police launched the Operation Jasmine inquiry in 2005 following the death of an elderly resident at another home.
The inquiry lasted nearly a decade and cost over £11m with detectives looking at 63 deaths.
Charges were brought against Dr Das and the Puretruce chief executive but the trial collapsed in 2013 after Dr Das suffered severe head injuries in an aggravated burglary at his home. He died last year aged 73.
Mr Williams said Dr Das was only interested in making money, rather than caring for the elderly, and condemned his “aggressive and threatening” attitude to the state agencies and his “deliberately duplicitous” actions.
Mr Williams criticised Dr Das, his chief executive Paul Black, and senior managers Peter Smith and Rachel Prichard.
“Dr Das was described in evidence by a number of witnesses including, significantly Paul Black and Rachel Prichard, as a manipulative, deceitful, dishonest bully,” he said.
“His attitude toward the state agencies and the regulatory requirements was clear from the outset of his involvement at Brithdir – at best it was cavalier and at worst deliberately duplicitous.
“He was known by the state agencies to be extremely litigious and was, I find, clearly determined to refuse to acknowledge any criticism or failure by him or his staff in the care given to his residents.
“I find, based upon the evidence that I heard, that he was aggressive and threatening to all who opposed him.”
Mr Williams said Dr Das had persistently failed to stick to statutory and regulatory requirements, especially around staffing levels.
“I am completely satisfied that his sole concern was making money from his business and that the needs of residents, their safety and their welfare played little if any part in his thinking,” he said.
“The expert evidence, whilst given in connection with individual residents, is that there was a culture at Brithdir of warehousing the residents, ensuring that they were fed and watered, although even that was often inadequate, giving them medication although not always appropriately and doing the bare minimum for them.
“The evidence in support of that expert opinion is simply overwhelming and stems, I find, from the focus of the management on maximising profit at
the expense of providing care. I find that such focus, attitude and culture represents the most gross dereliction of duty that could be imagined and amounts to a deliberate abuse of the elderly and vulnerable residents at Brithdir.”
Mr Williams did not criticise any individual from social services, the local health board or care watchdog but said there was a “focus on system and process” which meant the needs of residents were not always recognised in a “timely or appropriate fashion”.
He said the authorities should have taken more significant action against Dr Das in the autumn of 2004 following the deaths of Mrs Hamer and Mr Hickman.
“I find that the legislative and regulatory framework hampered significantly the steps which needed to be taken,” he said.
“However, and through no fault of their own, their very proper protective actions created a significant and possibly insurmountable hurdle to achieving what I have no doubt was a genuine desire to deal with the delinquent and abusive behaviour of Dr Das.
“In my judgment it was as plain as a pikestaff that in October 2004 there was a serious risk to the life, health and wellbeing of residents at Brithdir.”
Following the inquest, the Older People’s Commissioner for Wales said the shameful care experienced by residents at the Brithdir nursing home must never be allowed to happen again.
Helena Herklots, Older People’s Commissioner for Wales, said there had been many changes in the social care sector since the shocking events at the care home first came to light – to ensure there was never a repeat.
“I know that the pain and grief amongst families who lost loved ones following the shocking failures of care highlighted by this inquest are still very real, and I would like to pay tribute to the dignity with which they have made their voices heard and spoken up on behalf of their relatives,” she said.
“Their hard work and tenacity over many, many years has provided much needed, although often very painful, answers about the catalogue of failures, at both an individual and system level, which resulted in dehumanising and degrading treatment that ultimately contributed significantly to the deaths of their loved ones, vulnerable older people whose trust was betrayed in such an appalling way.
“Today’s findings underline why the changes we have seen across our social care system in the years since these failures occurred have been so important, and why learning and work to deliver improvements must continue to ensure that older people never again experience the kind of shameful care that the residents of Brithdir sadly endured.”
Blaenau Gwent MP Nick Smith said there was likely to be many more families who recognise the poor care loved ones suffered in homes owned by Dr Das.
“I’m glad that this inquest has documented Dr Das’ disgraceful behaviour and the appalling treatment that led to the deaths of elderly residents in his care,” Mr Smith said.
“Residents and their families will take small comfort from the coroner’s findings, although I hope that some closure has been provided given that Dr Das was never held to account in the courts.
“Following Operation Jasmine, I successfully fought to secure a change in the law so that care home owners could be personally prosecuted for cases of neglect.”