'My father deserved a better death' - York care home fined £160,000 over death of Dunkirk veteran

Alfred Colley - who was a great-grandfather of ten and the former head teacher at Lord Deramore's Primary School in Heslington  - fractured his hip during a fall at Lamel Beeches care home in Heslington Road but was discharged back to the care home after treatment in hospital.

Less than four weeks later he fell out of bed and re-fractured his hip. He died in hospital.

A court has been told that this fall was avoidable if Lamel Beeches had followed correct procedures around bed rail safety.

The Joseph Rowntree Housing Trust, based in York, pleaded guilty to two counts of failing to provide safe care and treatment with one offence resulting in avoidable harm to a resident, Mr Colley, and a second offence resulting in people using this service being exposed to a significant risk of avoidable harm.

It was ordered by Leeds Magistrates’ Court to pay £163,185.15 in fines and costs following the prosecution by the Care Quality Commission (CQC).

Mr Colley was a well known Dunkirk veteran and had been president of Fulford Golf Club.

Michael Colley, Alfred’s son said in a victim impact statement: “Although my father was very old and increasingly frail, I was still able to take him out for brief trips, and he maintained his former interests in golf, rugby and cricket as a spectator. He engaged enthusiastically with family matters, taking particular delight when new great grandchildren visited.

“Any bereavement is distressing, but these circumstances have made my father’s death particularly so. At the age of 98, death is not an improbable event. However, my father underwent unnecessary pain and distress. He deserved a better death.”

A safety consultant had previously identified that 14 beds at Lamel Beeches needed bed rail extensions to prevent the occupants falling – but the provider had not authorised the work, until after Mr Colley’s accident. There were four other incidents where Mr Colley had become trapped in the bed rail, or attempted to climb over it, prior to breaking his hip.

When CQC inspectors visited the care home in November they found concerns around the use of bedrails used by all ten people they checked on, suggesting that insufficient action had been taken to deal with risks or to keep people safe.

Upon his death in 2015, The Press ran tributes to Mr Colley in an obituary article.

In 1996, he had told The Press how he had joined the local territorial battery of the Royal Artillery just before the war started and, after being evacuated from Dunkirk, travelled from Dover to Bristol to a great reception from a local family. "We hadn't washed or shaved for several weeks but a wonderful family took us into their home and shared their rations with us for a week," he said.

He later worked at the Control Commission headquarters for Germany in St James Square, London, and then, after being demobbed, he trained to be a teacher.

He eventually became head of Lord Deramore's Primary School in Heslington in 1961, remaining there until 1978.

Mr Colley was president of Fulford Golf Club from 1999 - 2002 and continued playing golf into his 90s, only stopping after a series of strokes.

Debbie Westhead, CQC’s deputy chief inspector for adult social care said: “It is clear that the provider in this case had failed to keep safe the frail people in its care. They had not ensured that the bed rails were being safely used. Risk assessments were not suitable, staff had not been trained and they had not taken action to deal with the risks which had been identified.

“This was avoidable. We know that Mr Colley had fallen out of bed, or become trapped in the rails a number of times - but still too little was done to keep him safe.

“Taken together, the provider's poor governance and leadership at the home led to unsafe care and treatment on the part of its employees and it is for this reason that we have taken action in this case. If we find that a care provider has put people in its care at risk of harm, we will always consider using those powers to the full to prosecute those who are responsible."

The Joseph Rowntree Housing Trust was fined £100,000 for failing to provide safe care and treatment to Mr Colley and £50,000 for failing to provide safe care and treatment which exposed people to a significant risk of avoidable harm. They were also ordered to pay the prosecution costs of £13,000.15 and a £170.00 victim surcharge.

Shaun Rafferty, strategic director of communities at the Joseph Rowntree Housing Trust (JRHT), said: “We fully accept the court’s judgment and deeply regret the missed opportunities in the lead up to Mr Colley’s sad death. We wrote to Mr Colley’s family immediately after the incident occurred and apologised fully. We are deeply sorry to Mr Colley’s family and offer our sincerest condolences to them.

“We have co-operated fully with the CQC’s investigation and worked closely with them to quickly make the necessary improvements. We fully recognise there have been issues in parts of our services. This is not acceptable and we are working hard to rectify them.

“We have a new leadership team in place and we are delivering an improvement plan so that residents experience the best possible service. Eight out of nine of our care settings have a ‘Good’ rating from the CQC, including Lamel Beeches, and we will continue to build on this progress.

“We want to reassure our residents and our families in all our care homes that they are safe and will continue to receive high quality care.”

Last month the trust was fined £78,000 over a health and safety breach discovered during the investigation into the death of a resident at Red Lodge, New Earswick.  

Dora Strickland, 90, died after jumping to her death through a second floor bedroom window at Red Lodge, New Earswick. A jury convicted the Trust of not having a proper risk assessment for Red Lodge but acquitted it of exposing residents to the risk of jumping out of windows.