The family of an elderly dementia victim have spoken out at the care she received at an island nursing home - after she was found tied up in her nightie on two occasions shortly before her death.

When Eileen Ranson’s mum Glenda Critchley, who had advanced dementia, died in December 2015 just a few weeks short of her 96th birthday the family initially thought it was case of accepting the inevitable and celebrating a long life well lived.

But then events took a sudden and shocking turn.

Eileen said: ’Mum died on December 15 and I was relieved because she was in a weary state, she’d had enough, she wasn’t going to recover. I wanted her to be released from the torment of the dementia.

’She died on the Tuesday night so we started to plan a funeral: it was just before Christmas so we couldn’t have it until early January and we were going ahead with that.

’Then on the Saturday morning at nine o’clock the doorbell went and there were two police officers there who came to explain that there had been some complaint about the home. They didn’t tell us exactly what, but there were concerns about my mother’s care.

’Obviously it was quite shocking to hear that.’

It turned out that one of the staff from Beaconsfield had reported finding Glenda being restrained by being tied up in her nightie just a few days before she died.

Eileen said: ’I was shocked and saddened when I was told the detail of what had happened to my frail, helpless 95-year-old mother and this has lived with me ever since.’

Police at the time described her death as ’unexplained’.

Five members of staff at the home were suspended while a joint investigation was carried out by police and the Department of Health and Social Care’s Safeguarding adults team.

The investigation concluded that Glenda’s treatment at Beaconsfield was not a contributory cause to her death.

This was confirmed at the inquest into her death when Coroner John Needham concluded she had died of natural causes, primarily from aspiration pneumonia as a result of her dementia.

Giving evidence at the inquest, a member of staff at the nursing home described coming into Glenda’s room in the morning at the start of her shift.

She said she was horrified to pull back the covers and find her nightie had been tied in such a way that she couldn’t move.

’The back of the nightie had been pulled between her legs and tied to the front of the nightie in three knots on top of each other,’ she said. ’There was no chance Glenda would have been able to undo it. The top of the nightie was also tied.

’Her arms had been put inside with her elbows bent. The right shoulder of the nightie had been pulled around the back of her neck and been tied in three big knots again.’

The Coroner found the issues of restraint were not connected or contributory to her death. He also found no distinct evidence to back up allegations of over-medication.

But in relation to the tied-up nightie, he said: ’I’m satisfied this was an inappropriate use of restraint in respect of Glenda and the evidence is that it shouldn’t have occurred.’

The Coroner said that because the issues of restraint were not connected to her death, he was not in a position to make a recommendation. But he said it was ’not something to be repeated in the care of anyone’.

A statement from the DHSC reads: ’The department responded promptly to concerns regarding Beaconsfield, both from a regulatory and safeguarding perspective, and continues to work with this provider to respond to concerns about care.’

Adorn Domiliciliary Care Ltd, which runs Beaconsfield, was offered the chance to comment but it has chosen not to do so.

BACKGROUND: GLENDA’S LIFE

Glenda, who had lived in Blackburn, Lancashire, lost her husband, Bruce, in 1990 and became very lonely.

Eileen and her husband, Richard, invited her to come and live with them in Laxey.

Glenda also had a son, Bill, four grandchildren and five great-grandchildren To them, Glenda was a much-loved mum and ’Nana’.

They remember her love of dogs, her lemon drizzle cake and prize-winning parkin, and her little garden with the strawberry patch.

In her early 90s Glenda began to show the first sign of dementia and the highly intelligent woman, who had once won a scholarship to Liverpool University and loved reading and crosswords, began to decline.

Eileen recalls: ’Eventually it got to the stage where she was incontinent. It took two people to bathe her and she couldn’t be left alone.

’When it got to the point where she could no longer walk we just couldn’t cope.’

Like many families in this position it still wasn’t an easy decision to put Glenda into nursing care. After looking around at several options they chose a private nursing home, Beaconsfield in Ramsey, where she had already had spells of respite care, and she went to live there in December 2014.

Although the home lacked a specialist dementia unit, Eileen said: ’She went in because she couldn’t walk and I had assumed that, being a nursing home, they would be able to help her regain some of her mobility. She did initially but then she would forget that she couldn’t walk and she would try to walk and she fell quite badly a couple of times.’

In August 2015, social services became involved after an officer from the registrations and inspection team went into the home and said that it wasn’t meeting Glenda’s psychological needs. She was made an adult protection case.

Eileen said Beaconsfield wrote to her to say it was terminating the contract as its staff could no longer cope with her mum.

The Ransons were left with few options.

They tried a number of other homes in the island but couldn’t find anywhere to take Glenda. At one point it was suggested that the family might fork out a further £1,000 a week to pay for extra carers to go into the home.

Eileen says: ’She wasn’t easy latterly. I could understand that: she shouted out, she did peculiar things. Social services couldn’t find anywhere else for her in the island, they were even talking about sending her to England.

’Whilst we were concerned about the findings of the registrations and inspection team we didn’t want her to have to move at that stage in her life. All the agencies and professionals thought that Beaconsfield should be able to cope with more training and more awareness, so they were trying to offer this support.’

The Ransons appreciate that there are a number of very good specialist dementia units on the island but their experience with Glenda’s care has left them feeling that a number of issues around elderly nursing care should be resolved.

Dementia is not exactly a rare condition these days and one might imagine that, if a nursing home that was costing around £4,000 a month could not cope, then Social Services or other concerned agencies should be able to find a place somewhere that was suitable.

’It was a systematic failure. I just hope lessons can be learned,’ says Eileen and she adds: ’If you read this in the paper you would think: "Gosh, I wouldn’t have thought anything like that went on in the Isle of Man" would you?’

STATEMENT FROM THE DEPARTMENT OF HEALTH AND SOCIAL CARE:

Mrs Glenda Critchley

The Department of Health and Social Care (DHSC) wishes to extend its sympathies to Mr and Mrs Ranson following Mrs Critchley’s death and what then must have been a very difficult period leading to the inquest earlier this year.

The DHSC’s Registration and Inspection Unit (R&I) is a stand-alone regulator which ensures compliance with the regulations and standards associated with the Regulation of Care Act 2013. As part of its role, R&I is required to carry out regular, unannounced inspections of all regulated services, including those in the private sector such as the Adorn Domiciliary Care Limited Beaconsfield Tower Nursing Home (Beaconsfield). Reports of these inspections are publicly available.

An inspection by R&I in August 2015 (which led to a report published in January 2016 - link) identified that Beaconsfield was not meeting Mrs Critchley’s care needs; and the concerns were such that an ’adult protection’ referral was made to the DHSC Adult Social Care Safeguarding Team.

The DHSC worked with Beaconsfield through the autumn of 2015, bringing together specialists from Mental Health Services, Social Care and R&I to support the home in meeting Mrs Critchley’s care needs.

Whilst the department provides specialist dementia care services for people with challenging behaviour, it does not provide any nursing care - this has been traditionally offered by the private sector.

Improving standards of care is always a partnership between the regulator and the service provider; but the care provider is required to ensure that they are able to meet the needs of their residents at all times.

Each provider must have a ’statement of purpose’ which specifies the type and level of care that they are able to provide. This is intended to help families when selecting a home, and is used by the regulator to ensure that providers are reaching an acceptable standard of care.

With regard to Mrs Critchley, approaches were made to other nursing home providers in the Isle of Man, with the support of social work staff, but her family concluded that a move would not have been in Mrs Critchley’s best interests at that time.

Both R&I and the Adult Safeguarding Team have continued to work with Beaconsfield to ensure that regulations and standards are met.

The department’s powers to intervene in a private care provider are limited to those in force under the Regulation of Care Act. However, the department is currently developing the legal framework for the Safeguarding Board, which is independently chaired, and place upon all relevant bodies a duty to co-operate, and to raise awareness of the need to safeguard and protect vulnerable children and adults. It is planned that this will be open to consultation later this year.

There are more than 800 rooms in residential and nursing homes in the Isle of Man, and the majority of those providing care for older people do so very effectively. The DHSC is currently reviewing its specialist dementia services as there is currently a greater need for those people in the earliest stages of dementia who can remain in standard residential home but with enhanced care and they are looking to shift the focus of their resources accordingly.

The DHSC will continue to work with care providers across the island to promote high quality care.

If anyone has concerns about any care service, they can contact either the R&I Team or the Adult Safeguarding Team by calling 686179 or via email [email protected]