How a great-grandmother came to suffer a fall which contributed to her death will remain a mystery, an inquest heard.
Rose Mary Sharp, 85, was found in the bathroom door of her assisted living apartments in Woodridge Gardens in Washington just after midnight on Christmas Eve, last year.
I myself raised serious concerns that we had as a familyDaughter
She was taken to Sunderland Royal Hospital where she was found to have a fractured pelvis, but died on January 12 after contracting an infection.
Sunderland Coroner Derek Winter was told Mrs Sharp’s family had raised concerns in the weeks leading up to the accident over her level of care by Housing & Care 21, which runs the accommodation, and had issues with a falls risk assessment.
The retired factory worker, who suffered from chronic obstructive pulmonary disease (COPD), had pressed her pendant alarm several times after she fell to alert staff, the inquest at Sunderland Civic Centre was told.
But, because they were tending to another resident, there was a delay of several minutes before they got to to dementia sufferer Mrs Sharp, by which time she could not remember how she fell.
Mrs Sharp, a widow, complained of back and shoulder pain and had a graze to her cheek. She told staff she thought she had bumped her head. Her family were informed and an ambulance was called.
Pathologist Dr Matthew Theodosiou said that, aside form her COPD diagnosis, Mrs Sharp also had severe coronary heart disease and pneumonia.
He said: “The fracture to the pelvis would have caused reduced her mobility which is a significant risk factor to developing pneumonia and I think it has contributed to her death.”
Mrs Sharp’s daughter Linda told the inquest she believed her mother may have fallen before, because she’d had an injury to her arms, but that the incident had gone unrecorded.
She said she believed the falls risk assessment had been inadequate, adding: “I raised serious concerns that we had as a family. She couldn’t really remember or retain information and when she got up she was extremely shaky.”
Mr Winter said: “On December 24, Mrs Sharp was admitted to Sunderland Royal Hospital following an unwitnessed fall at her accommodation.
“It is evident that there has been a fall and Mrs Sharp was unable to recall how the fall had come about.
“I heard evidence that there has been a falls risk assessment whilst Mrs Sharp was within Housing 21. They did their own risk assessment. I also heard evidence that the community matron had also carried out a falls risk assessment”
Recording a conclusion that Mrs Sharp died of natural causes, contributed to in part by an unwitnessed fall, Mr Winter said the reduced mobility after her pelvic fracture had been a risk factor for her.
“She did not have the physical resilience to recover due to pulmonary and heart conditions,” he said, adding that: “The fracture was more than minimally or trivially contributory to Mrs Sharp’s death.”
He told Mrs Sharp’s family: “I do not underestimate the other issues you have yet to resolve. It is clear that Mrs Sharp is deeply missed and will continue to be sorely missed.”
A Housing & Care 21 spokesman said: “We had carried out a full and proper risk assessment and our staff acted appropriately when they found Mrs Sharp had fallen.
“Our thoughts remain with the family and we will continue to talk to them about any outstanding concerns they have.”