A Weyhill care home has said it has made changes following the death of a resident after he fell at the home.

Millway House, located on Amesbury Road, said that it had introduced permanent staff on duty in the lounge area of the facility, and improved the speed of producing care plans, following the death of Donald Thomas Edward Gray.

Donald Gray fell at the home on June 22 2020, and later died following the fall at Basingstoke Hospital. His daughter, Paula, said that she was “appalled” by the care her dad received.

The operations manager for Sears Healthcare, which owns Millway House, Sara Gallagher, said that care for Donald “was not provided to the standard [Paula] or the company would expect”.

The coroner, Rosamund Rhodes-Kemp, declared a verdict of accidental death.

Donald was born in 1939 in Isleworth, London, and worked as a metal worker for much of his life. In his later years, he lived in Stockbridge with his partner, Jeannie. He had a number of health conditions, including type II diabetes, chronic kidney disease and dementia. Towards the end of his life, he was suffering from chronic renal failure, and was given palliative care.

Following admission to Portsmouth Hospital, Donald fell after getting out of bed, and hit his head on a fridge. Scans showed brain damage associated with dementia, and he was transferred to Winchester hospital. Due to the pressures on the NHS during the pandemic, he was then transferred to Millway House, against the wishes of his daughter.

“I felt it wasn’t the right place for my father to go,” said Paula. “I wanted him to go to a hospice.”

However, she was reassured by the then-manager of the care home, Sarah Brown, and was asked to bring sentimental items to the home to help settle Donald including pictures of his wife and some treasured clocks. However, following an incident in which Donald called police from the home while in a state of delirium, Paula visited Millway House and said she was “appalled.”

“Sarah made a point of saying they [sentimental items] would settle him,” she said. “A few days later, I went on a booked visit and they were left on the floor in the corner of dad’s room and the clothes hadn’t been unpacked. I was appalled.”

Donald also hadn’t had his teeth brushed, or been showered, since he arrived at the home. The coroner said that the situation was “heartbreaking” in his final weeks.

Sara Gallagher admitted that Donald’s care “was not provided to the standard you [Paula] or the company would expect”.

The coroner also raised concerns that a paragraph in the letter sent to Paula regarding an investigation, detailing that Donald had not been changed, was not present in the version of the letter sent to the coroner.

“I’ve never come across this before,” she said. “The letter does not have that paragraph.”

She continued: “I would like an explanation of how that’s happened as evidence to the coroner has a certain obligation.”

Sara said she would provide an explanation following the inquest.

A few days after Paula’s visit, Donald was taken outside to have a cigar, and following this, was escorted to a seat in the lounge. Two members of staff were on duty, and were subsequently called away to attend to other patients. As one returned, they saw Donald walking into the garden, and despite attempting to reach him, he fell and fractured his femur.

The coroner quizzed the manager of the care home at the time, Sarah Brown, on why the lounge could be left unattended, saying that she was “struggling to see why they could leave.”

Sarah said that the home did not have a policy of always having a carer in the lounge at the time, while staff that would normally have checked on other residents could not move due to the bubbling of floors in the care home due to Covid restrictions.

She said: “I think the people in the room are equally at risk as those in the lounge, and he needed to check what was going on.”

Sara said the carer had made “what he felt was the best decision, clearly it wasn’t, but he felt it was.”

She said that the Covid pandemic “was really difficult for people in the home to manage”.

The coroner said that the accident was preventable, saying: “If someone had been in the lounge, this would have been avoided. I’m not suggesting the care assistant shouldn’t have gone to the assistance of someone he thought was at risk, but someone should have been there to take his place.”

Following the fall, Donald was taken to Basingstoke Hospital, where he was in “extreme pain”. Following a decision that an operation would not be in his best interests, Donald was placed on an end of life pathway and passed away on June 25, 2020, at the age of 81.

Sara subsequently carried out an investigation into Donald’s death, finding that the standard of Donald’s care “clearly wasn’t up to the standard expected”.

She said that care reports for all patients now had to be made within seven days of arrival at the home, and that a member of staff is always on duty in the lounge, as part of changes made in light of Donald’s death.

Paula then gave a statement from the family, and said that she found the care of her father at Millway House “upsetting”.

“I’m not sure how the care home be classed as end of life care after the appalling care they showed to my father in so many ways,” she said.

After hearing all the evidence, the coroner delivered a verdict of accidental death.