Care home deaths due to neglect, inquest finds

An inquest into the deaths of six care home residents has ended – with five of the deaths determined to have been due to neglect.

The inquest centred on the deaths of Brithdir Nursing Home residents Stanley Bradford, 76, Evelyn Jones, 87, Edith Evans, 85, June Hamer, 71 and William Hickman, 71.

Assistant Coroner for Gwent, Geraint Williams, ruled these deaths were due to neglect, while a sixth resident, Stanley James, 89, had died from natural causes.

The deaths all happened between 2003 and 2005, with the care home closing in 2006.

The inquest heard how residents were “dehumanised” by staff and the standard of care “was not acceptable”.

Residents had their incontinence pads changed in the care home’s lounge with other residents present, the inquest was told.

The coroner said residents were “simply kept, fed and watered”, while pressure sores suffered by the residents were kept secret from their families.

The coroner also said more action should have been taken against Dr Prana Das, who was the director of Puretruce Healthcare Ltd, which operated a host of care homes across south Wales – including Brithdir.

Dr Das was facing charges of fraud as well as Health and Safety charges when his trial collapsed in 2013 after he suffered a brain injury following an attack by burglars. He died in January 2020.

Dr Das was at the centre of a £15m police investigation – Operation Jasmine – which was launched in 2005 following the death of a care home resident in Newbridge.

Police investigated the deaths of 63 people in care homes across south-east Wales, including two in Caerphilly County Borough.

Caerphilly MP Wayne David raised concerns about the practices of Dr Das’ company in Parliament in 2005.

Speaking after the eight-week inquest had ended, Mr David said: “What happened at Brithdir was the result of the actions, inactions and failings of a number of individuals and agencies. But it is clear that by far the greatest measure of responsibility must rest with the late Dr Das.

“Along with the Chief Executive of the company which owned the care home, Dr Das was very well aware of the huge inadequacies and failings of the home and yet did nothing about them.  Indeed, he wilfully obstructed efforts made by the Regulatory Bodies to bring about improvements at Brithdir. 

“Unfortunately, Dr Das was more concerned about his profits from the care home, than the well-being of the residents.”

Stanley Bradford

Brithdir Nursing Home resident Stanley Bradford was 76-years-old when he died.

Mr Bradford – an ex-miner and a father-of-five – had been a resident at the care home for three months before his death on September 29, 2005.

In August 2005, he was admitted to Prince Charles Hospital in Merthyr Tydfil, where he was found to be dehydrated and malnourished.

His daughter, Gaynor Evans, told the inquest her father “resembled someone from a prisoner of war camp”.

Ms Evans said her father’s condition improved during his six-week stay at the hospital, but he died ten days after returning to the care home.

Edith Evans

Edith Evans, a resident at Brithdir Nursing Home, was 85-years-old when she died in September 2005.

The inquest was told that staff at Prince Charles Hospital in Merthyr Tydfil were shocked by Mrs Evans’ condition after she arrived at the hospital in the weeks before her death.

When she arrived at the hospital, she wasn’t accompanied by any care home staff, nor did she have her medical history or family contact details with her.

Mrs Evans, who had dementia, arrived at the hospital “very agitated” and “unclean”, hospital nurse Rachel Pulman told the inquest.

Ms Pulman described Mrs Evans’ “matted” hair and said she was “dirty from faeces” when she arrived at the hospital.

Mrs Evans’ death was caused by sepsis, which had developed at the site of a peg feed tube, which went into her stomach to allow her to consume food. It was discovered that Mrs Evans had had the infection for seven weeks before she went into hospital.

Gail Morris, Mrs Evans’ niece, told the inquest her aunt’s death was “painful and distressing”.

Evelyn Jones

The inquest heard how Evelyn Jones, who had dementia, died in agony at hospital in November 2005 after suffering pressure sores on her back, which had been described by hospital staff as smelling like a “dead cat”.

Hospital staff took photos of the sores and contacted social services, as well as the police, describing them as the worst they had ever seen.

Mrs Jones had been submitted to Prince Charles Hospital with a urinary tract infection.

Her family had been unaware of the injuries until Mrs Jones had gone into hospital.

Mrs Jones died from sepsis due to the pressure sores becoming infected.

June Hamer

June Hamer, who had dementia, died after being taken to Prince Charles Hospital ospital in August 2004 with pressure sores sustained at the nursing home.

The coroner said an infected pressure sore played a part in Mrs Hamer’s death.

Mrs Hamer’s daughter and husband would feed her when they visited the care home, as they believed she wasn’t being care for properly.

William Hickman

William Hickman also developed pressure sores while at the nursing home.

When he went into hospital, he had 17 pressure sores on his body.

The coroner said “gross failings” had been a “direct cause” of Mr Hickman’s death.

Stanley James

While Stanley James’ death was not attributed to neglect, he developed numerous pressure sores while living at Brithdir Nursing Home.

However, the coroner did say Mr James’ sores were caused by neglect.