AN ELDERLY woman from Pontypool died in hospital after a series of falls at her care home, an inquest hearing was told.

Sylvia Cole, 82, died in January 2016, around 10 months after moving into Rowan House, a residential and nursing home in Pontypool owned by Summerhill Care Homes Group.

Senior coroner for Gwent Caroline Saunders was told how Mrs Cole, who had dementia, had been admitted to Nevill Hall Hospital several times after falling.

She fell on January 6 2016 and was discharged the same day, only to fall again the next day and be readmitted, CT scan revealing a bleed in her brain.

In a statement, her son Brian Cole said the family was "absolutely devastated" by her death, and had been concerned she was not receiving enough one-to-one support.

"A review should have been done after each fall," said Mr Cole, who added that his mother received care from 11am-11pm, but the family had wanted this to become 24-hour care.

Rowena Martin, Summerhill Group's head of care at the time of Mrs Cole's death, said it was her job to make sure a high standard of care was maintained.

She visited Rowan House in November 2015, and was concerned that nurses were not keeping residents' care plans updated. She said this was because of a "shortage of nurses".

At the time of Mrs Cole's death, she added, there was not a policy in place for the head of care to be made aware of residents' falls.


Ms Saunders asked Mrs Martin about the level of staff training at Rowan House.

"The company was very good with training," said Mrs Martin, adding that falls management was not part of mandatory training for Summerhill Group staff at the time.

Mrs Martin had not seen any referrals for Mrs Cole to receive additional one-to-one assistance.

Ms Saunders asked her about the ability of nurses to update care reports. She asked about a nurse, Andrea Din, who in her original statement said she had not received a full induction at Rowan House.

Mrs Martin said she "had no doubts" Ms Din "had the knowledge and skills of a nurse", but her level of English at the time meant she was not expected, nor required, to update care reports.

David Sapiecha, representing the Summerhill Group, asked Mrs Martin about the registration of nurses at Rowan House. He said the Nursing and Midwifery Council (NMC) required nurses to "demonstrate English to a level safe to practice nursing.

Mrs Martin agreed, and said all nurses would have been registered by the NMC before taking up their post.

Rachel Howells, contracted to visit Rowan House and give Mrs Cole 12 hours of one-to-one support said she would wash and dress, and then walk with her. In the afternoons, Mrs Cole's husband would visit, and the two would watch TV together.

Ms Howells said she made repeated comments in passing, to Rowan House's care and nursing staff, about the need to increase Mrs Cole's one-to-one care.

"I think she should have had 24-hour care, but my opinion didn't count," she said.

Mr Sapiecha asked if these comments had been made formally.

Ms Howells said they had been informal, though she had made several written comments in log books kept at Rowan House.

Natasha Young, who was a care assistant at Rowan House at the time of Mrs Cole’s death, said it was clear that Mrs Cole needed one-to-one care and that she believed her condition worsened towards the end of 2015.

Ms Young was on duty the second time Mrs Cole fell, shortly after 11pm. Mrs Cole had been sitting alone in her chair beside her bed before her fall, despite her family advising that she wasn’t allowed to leave her bed unattended after she had fallen earlier in the day.

Ms Young added that she helped Mrs Cole into bed after the fall, and she received one-to-one care for the rest of the night.

Jacqueline Jones, who was also a care assistant, said Mrs Cole would get agitated when her one-to-one support stopped at 11pm, and would stay up for most of the night walking the corridors.

Ms Jones added that it was policy to check on vulnerable patients every 15 minutes, but that it was not always possible due to high demand of the patients.

At the time of Mrs Cole’s first fall on January 6 at around 5am, Ms Jones had briefly left Mrs Cole alone in the corridor to tend to another patient.

She said she heard a bang and a scream shortly after leaving Mrs Cole, and returned to the corridor to find her on the floor.

Julie Stone, who was an assistant manager at the care home at the time but later resigned from her position due to stress caused by staffing issues and high workload, said she felt multiple carers at Rowan House did not have adequate knowledge to perform the roles.

She said Ms Din, who oversaw Mrs Cole’s care plan, openly lacked confidence when filling in care plans, and risk assessments for patients.

“Care plans were not filled in for Mrs Cole and others,” Mrs Stone said.

Brian Cole said his family had not received any information relating to his mother’s risk assessment and care plan despite asking for evidence since her death.

Mrs Stone added that she became stressed because she “didn’t have a clear outline” of her duties, and said she raised the matter of staffing issues to senior management at Rowan House and to the local authority.

Ms Saunders questioned whether requests for more staff and better resources were made “explicitly”.

On the morning of Mrs Cole’s fall, Mrs Stone said she was one of two nurses on shift, and that she was tending to another man who had fallen on a separate floor.