Staff failed to follow rules at Devon care home where seven died from Covid - coroner

Measures to protect residents from Covid at a care home where seven elderly people died were not “effectively or consistently” followed by staff, 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 died between March and April 2021 after contracting Covid while living at Holmesley Care Home, in Sidford.

The deaths all came at the height of the Covid pandemic when rules were in place intended to protect residents from infection.

During the two-week inquest in Exeter, it was alleged that some staff refused to wear face masks or PPE, that others continued working despite testing positive for the virus, and that lateral flow test results were ignored.

On Thursday 17 October, coroner for Devon, Plymouth and Torbay Alison Longhorn concluded that there were proper processes at the home but they “were not effectively or consistently followed” by all of its staff.

A family member of one of the residents placed seven red roses on a desk in the court to represent the residents who died.

A spokesperson for Holmesley Care Home said it acknowledged the coroner's findings and has made improvements to care provision in the home.

The inquest was told two staff members - manager Joanne Burchell and night-time nurse Christos Provistallis - had been arrested on suspicion of ill-treatment or wilful neglect, but no further action was taken against them.

It heard allegations that Mr Provistallis had ignored guidance to wear a face mask and told people he believed Covid-19 was a conspiracy.

Deputy manager Jemma Turner told the inquest about being telephoned by a care worker in the early hours of 2 March reporting several residents were ill.

“She was crying, saying, ‘Jemma, the residents are poorly, I don’t know what to do’,” Mrs Turner said.

“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’.”

Others alleged Mrs Burchell decided against sending sick staff home due to staff shortages and had ignored positive lateral flow test results putting them down to a "bad batch".

The inquest heard from the home's owner, Will Neal, who told the inquest he "felt uneasy" about Mrs Burchell's decisions, but said she made them "in the best interests and overall safety of the residents".

He also told the hearing he regretted not dismissing the nurse who had refused to wear a face mask.

"I feel really upset and I feel really disappointed," he said. "The situation of not wearing a mask, when he should have been wearing a mask appropriately, is really, really disappointing to hear."

The inquest heard staff had realised there was potentially an outbreak on the morning of 2 March, but days before six positive results had been ignored.

Three days later on 5 March, Mrs Turner contacted health watchdog the Care Quality Commission (CQC), Devon safeguarding and the police with her concerns about the outbreak.

Mr Neal said he did not know any of this until he was told days later by Mrs Turner in a whistleblowing email.

“When I did hear about that I thought that was unthinkable,” he said. “The idea that six people would be coughing, displaying symptoms of Covid-19, and tested positive, and we just ignored it and called the GP."

After hearing that two people had been arrested and interviewed by police following the Covid-19 outbreak, the relatives of those who died criticised the decision not to prosecute anyone.

Wladek Kock, whose mother Stanislawa Koch died, told the inquest the authorities did not have the "courage" to prosecute.

Sally Burns, the daughter of Mr Bampflyde, added she was "absolutely astounded" by how events unfolded.

Recording her conclusions, Ms Longhorn said: “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.”

She added: “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.

“I would highlight that evidence heard at this inquest related to only some staff at one care home.

“I would like to thank all the families of the residents, I recognise that some of the evidence may have been upsetting or difficult to hear and I understand their frustration that no criminal prosecution will be brought.

“I want to offer all of you affected by the loss of your loved ones my condolences, I really am very sorry for your losses.”

The coroner also acknowledged recent CQC reports which indicated there had been improvements at the home.

• Speaking after the inquest, Mick Koch said he still feels there hasn't been justice for families

Speaking after the conclusion of the inquest, Mick Koch, whose mother Stanislawa Koch died after contracting the virus, said he "still feels there hasn't been justice in the situation".

"We can see a small, creeping forward in improving situations in this sort of event, so the mismanagement of the Covid outbreak at Holmesley can't happen again.

"But fundamentally, we're still not overly happy with the CPS and the CQC judgements on the apportion of the blame, and whether or not they had cases that they could prosecute fully in court".

However, Mr Koch praised the coroner for her handling of the inquest.

"I think she's been very sensitive to all families concerned, and in the very final stages of her deliberations she came up with some very helpful points for the families," he said.

A spokesperson for Holmesley Nursing Home, said: "We have at all times co-operated openly, fully, and with complete transparency with these investigations and are grateful to note that the coroner recognised we had clear policies and procedures in place to deal with the pandemic.

"However, we also acknowledge the coroner’s findings that these mandatory policies and procedures were not always followed as consistently and effectively by some staff members as they ought to have been.

"We have taken the learnings from this period in 2021 to improve all aspects of care provision in the Home, which has since been reflected in the most recent CQC inspection in 2023, which rated the Home as 'Good'".

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