On 2 November 2017 I commenced an investigation into the death of Doris McCarthy, aged 92 years. The investigation concluded at the end of the inquest on 6 July 2018. The conclusion of the inquest was that Doris McCarthy died from natural causes as a result of a pulmonary embolism, with an underlying subdural haemorrhage caused by recurrent falls.

Mrs McCarthy became a resident of Baycroft Orpington on 19 September 2017 due to her reducing mobility, declining memory, recurrent falls and inability to take care of her personal needs in her own home. She had been placed as a resident directly following an inpatient stay in hospital, during which time she was identified as having a subdural haematoma, and at high risk of falls.

The General Manager, during the period of residence, gave evidence at inquest that Baycroft is a state of the art facility with sensors and alarms alerting staff of resident movements. This included a call bell system activated by sensors both in beds and chairs, and falls wrist watches.

The General Manager identified two ‘fall’ incidents whilst in the home on 20 and 28 September 2017. On both occasions Mrs McCarthy slid from her chair but the sensor system did not alert staff. The evidence given was that the system had frequent outages, and that it was not possible know when such an outage had occurred.