Staff failed to follow COVID safety rules at Devon care home where seven residents died - coroner
Some staff members at Holmesley care home are alleged to have not worn face masks or PPE while others continued to work despite testing positive and the manager ignored test results.
Thursday 17 October 2024 17:39, UK
Safety measures were not "effectively or consistently" followed in a care home where seven people died during the COVID-19 pandemic, a coroner has ruled.
William Wilkinson, 102, Doris Lockett, 92, Roy Gilliam, 96, Jean Hartley, 81, Susan Skinner, 70, Ronald Bampfylde, 92, and Stanislawa Koch, 93, all died in March or April 2021 after contracting coronavirus at the Holmesley care home in Sidford, Devon.
The deaths came at the height of the pandemic when rules intended to protect residents from infection were in place.
Alison Longhorn, area coroner for Devon, Plymouth and Torbay, told an inquest on Thursday that by rules and safety procedures not being followed, the home was put at "risk of infection".
"Whilst the nursing home had clear policies and processes to be followed to reduce the risk of infection and spread of COVID-19, these were not effectively or consistently followed by all staff working in the home," Ms Longhorn said.
"We have heard much evidence that some staff at Holmesley did not effectively or consistently follow clearly defined processes regarding infection prevention and control and that their practice of not doing so potentially put that home at risk of infection."
It was alleged some staff members did not wear face masks or PPE while others continued to work despite testing positive and manager Joanne Burchell ignored test results.
Staff are also believed to have realised there was a potential outbreak on the morning of 2 March, but days before six positive results had been ignored, with Mrs Burchell attributing it to a "bad batch" of tests.
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Guidelines for the home stated that if a staff member tested positive for COVID, they should be sent home, then any resident they had been in close contact with must be isolated for 14 days and all staff and residents must be tested.
One nurse, Christos Provistallis, allegedly refused to wear a face mask and told people he believed COVID was a conspiracy, staff said.
He later ended up in intensive care after contracting the virus.
Deputy manager Jemma Turner contacted the Care Quality Commission (CQC), Devon safeguarding and the police with her concerns after she received a call from a care worker in tears.
"She was crying, saying, 'Jemma, the residents are poorly, I don't know what to do'," Mrs Turner told the inquest.
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"I said, 'Where's the nurse?' and she said, 'He's refusing to wear a mask and he's walking around the home and he's saying that COVID is a conspiracy'."
Will Neal, a director of the company which owned the home, said he was "disappointed" and "shocked" and described some of the allegations made as "absolutely unacceptable".
He said he was unaware of the outbreak and said the idea that six people were displaying symptoms and were ignored was "unthinkable".
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Ms Longhorn said evidence heard at the inquest related to only some staff members and that she had not found there to be negligence at the care home.
The coroner also acknowledged recent CQC reports which indicated there had been improvements at the home.
Both Mrs Burchell and Mr Provistallis were arrested and interviewed on suspicion of ill-treatment or wilful neglect, but the Crown Prosecution Service decided there was not a realistic prospect of conviction.