Family Represented in Inquest Following Fatal Care Home Incident

Dean Wilson LLP represents the family of Mr W in relation to the circumstances surrounding his death following a fall at Fairdene Lodge Residential Care Home in Brighton in June 2024. An Inquest into his death took place on 14 January 2025 before HM Coroner Joseph Turner at Brighton Woodvale.

Background

Mr W., aged 80, had been residing at Fairdene Lodge under a Deprivation of Liberty Safeguards (DoLS) authorisation. His care home records indicated a longstanding history of frequent falls, including six falls at the care home requiring A&E attendance in the year leading up to his death. 

In late June 2024, Mr W. suffered a fall that resulted in an A&E admission. He was returned to the care home later the same day. Only hours later, in the early morning of the following day, he sustained another serious fall whilst attempting to use the stairs without sufficient supervision or protective measures in place.

Following the fall, ambulance records indicate that Mr W. went into cardiac arrest, and CPR was carried out at the direction of the 999 call handler — despite a Do Not Resuscitate (DNR) decision being in place. Concerningly, the DNR could not be located by care home staff at the time of the emergency, preventing ambulance crews from acting in accordance with Mr W.’s wishes.

Mr W. suffered multiple traumatic injuries, including fractured ribs, a fractured collarbone, and a deep laceration extending to the tendon. None of these injuries were recorded in the care home’s accident report, which caused substantial shock and distress to the family when the true extent of his injuries became clear at hospital. His condition deteriorated, and Mr W. sadly passed away shortly afterwards.

Mr W.’s family raised serious concerns about the quality of care provided at Fairdene Lodge.

Brighton & Hove City Council subsequently red flagged the incident and undertook its own investigation into the home’s conduct. In particular, it noted discrepancies between the care home’s account and ambulance records regarding the number of steps involved, as well as conflicting accounts about whether CPR was administered. It also highlighted difficulties locating the DNAR documentation at the time of the emergency, and concerns raised by the family about the initial communication of the severity of injuries and subsequent handover/recording practices. The enquiry concluded that there were wider organisational learning points and that the matter was referred for monitoring by quality/regulatory teams.

Inquest

Mr W.’s family contacted Dean Wilson LLP to assist with navigating the Inquest process. A barrister was instructed under a no win no fee agreement to advocate for the family at the Inquest.

During the review of medical records, care home documentation, and the 999 call recording, it became clear that there were the following serious inconsistencies:

• The 999 audio confirms that CPR was taking place throughout the call, directly contradicting written statements by staff members who asserted that no CPR was performed.
• Injuries evident at hospital were not recorded by the care home.
• The DNR documentation could not be produced during the emergency, despite and DNR being in place and held by the care home.

Given these issues, we were successful in convincing the Coroner to order key care home staff to attend and give live evidence, including the author of the risk assessment & accident report; and care home staff in attendance on the night of the fall. 

Ensuring the family’s voice was heard was central to our approach. Questions were put to staff regarding their supervision of Mr W., the absence of safeguard measures, and the accuracy of their accounts.

Civil Claim

Following the conclusion of the Inquest, we continued to assist the family by bringing a civil claim on behalf of Mr W. for the pain and suffering he endured before his death. The claim concluded with an out of court settlement, providing a sense of accountability and closure.

Supporting the Family Through the Process

Mr W.’s family witnessed the profound suffering Mr W. experienced in his final days and remain deeply distressed by the circumstances surrounding his death. They are determined to ensure that lessons are learned and that appropriate safeguards are implemented to prevent similar tragedies occurring in other care settings. Brighton: Man died after falling down stairs at care home | The Argus 

This claim was handled by Jessica Edwards on a no win no fee agreement, with the support of Thea Wilson and Liz Boulden of 12 King’s Bench Walk, who provided specialist Inquest advocacy and advice.

For further information on how we assist families following a death in a care setting, please visit our Inquests page or contact our team on 01273 249200.