Midlands Nursing Home Case

An inquest jury has today returned a natural causes verdict into the death of a Solihull pensioner, who died unexpectedly just ten days after being admitted to the notorious Maypole Nursing Home in Birmingham, where 27 residents died in just one year.

The two-week investigation heard how 77 year old war veteran Leslie Vines from Cranmore Road, Shirley, was sedated and placed in a ‘bucket chair’ which may have restricted his ability to breathe when he had contracted a chest infection at the home.

A leading medical law expert from Irwin Mitchell Solicitors, who has led the legal fight on behalf of Mr Vines’ family, has now called for bucket chairs to be outlawed in elderly care homes.

The pensioner, who had both Alzheimer’s and Parkinson’s Disease, was considered physically fit when he was discharged from Heartlands Hospital, after six months,  to the Maypole on 27th August 2002. However, the inquest heard from medical and nursing experts that his condition deteriorated rapidly and this was not communicated to the family before he died just ten days later, on 7th September 2002, from broncho pneumonia.

Mr Vines’ death was one of 16 flagged by the Commission for Social Care Inspection as giving ‘serious cause for concern’ after the home was suddenly closed down in March 2003 following a surprise inspection which unearthed a catalogue of failings.

The two GPs who owned the home, Dr Jamalapuram Hari Gopal and his wife Dr Praturi Samrajya Lakshmi, were later struck off by the General Medical Council for serious professional misconduct.

In June 2008, three Maypole nurses responsible for the day to day care of patients, including Mr Vines - Nursing Manager Kathleen Smith and nurses Mary Casey and Carol Bushell - were struck off by the Nursing and Midwifery Council, having been found to have committed 16 counts of professional misconduct, including wrongful medication, the inappropriate restraint of patients and a range of hygiene and personal care failings which left elderly and vulnerable residents in an “undignified” state.

Birmingham Coroner, Aidan Cotter, had earlier ruled that the exact nature of these investigations and their outcomes were to be withheld from the jury until they had reached a verdict.

Despite requests from Mr Vines’ family, the Coroner had refused to conduct an inquest until a landmark legal battle at the High Court in London by the family’s solicitors, Irwin Mitchell, successfully quashed his decision. This paved the way for Justice Secretary, Jack Straw, to review the case and in May 2008 he ordered that an inquest should take place.

Victoria Blankstone, a medical law expert, who has acted on behalf of the family since 2003, having given much of her legal representation free of charge over the past years, said: “This inquest has not just been about reaching a final verdict, but has been a search for answers as to how a vulnerable elderly man could be let down so badly by the health professionals whose duty it was to care for him.

“Despite previous high profile investigations, including both a GMC and NMC hearing, we still had not heard about what happened to Mr Vines in his final days.

“It is extremely regrettable that Hazel and her family have had to wait seven years to find out exactly how and why their father died. We firmly believe that an inquest investigation into his death – and indeed the other 15 residents whose deaths gave inspectors ‘serious cause for concern’ - should have been held much earlier without the need for separate Judicial Review proceedings.

“During this inquest, we have publicly heard for the first time, how bucket chairs are used for patients who are immobile, such as after a severe stroke, but their use for mobile patients can amount to restraint.  Despite being mobile, Mr Vines was placed in a bucket chair.

“None of the earlier investigations dealt with this issue or examined how this type of chair not only restrained Mr Vines’ movements but also could have made it difficult for him to breathe properly.  We heard evidence at the inquest how since 1992, there have been concerns about the risks of using restraint to immobilise patients. We are now calling for these chairs to be banned in elderly care homes.

“The inquest also revealed that Mr Vines’ family thought that he was very well cared for over the 6 months that he was at Heartlands Hospital, even though it was a busy surgical ward, with no special provision for dealing with his special mental health needs. The family anticipated he would be even better cared for at the Maypole – a home which claimed to be a specialist EMI unit – but was sadly lacking in even the most basic care provision.

“During the inquest we had the opportunity to examine the actions of government agencies who visited and reported on failings at the Maypole on no less than 17 separate occasions before finally taking the decision to close it down.

“This highlights the much wider issues of both a desperate lack of good specialist care for our vulnerable elderly in this country and a reliable method of ensuring standards by the various government inspection bodies are upheld – something which we will continue to campaign on.”

Mr Vines’ daughter Hazel Bicknell said: “We have fought for seven long years for this inquest. Some people may question why we wouldn’t just let things lie and get on with our lives.  My mother, quite wrongly, blamed herself for Dad’s death. She felt it was all her fault for allowing him to be admitted to the Maypole. She never got over Dad’s death and she died just months afterwards in March 2003. I’m convinced she died from a broken heart and the grief of not knowing what happened to Dad. This fight has been about getting answers so that I can finally lay to rest the memory of both my parents.”