AN ELDERLY woman with dementia from Pontypool who required extensive one-to-one care died in hospital after suffering falls at her care home when she was left alone, an inquest has heard.

And following the inquest into her death, her family said they felt let down by social services, the police and the health board after it took more than four years for the hearing to take place.

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

On Tuesday, February 11 and Wednesday, February 12, an inquest at Newport Crown Court heard how Mrs Cole had been admitted to Nevill Hall Hospital several times after falling at the home.



She fell on the morning January 6, 2016, and was discharged from hospital, only to fall later that evening and be readmitted to hospital the following morning, where a scan revealed a bleed inside her brain.

In her summing up of the case, senior coroner Caroline Saunders said it had been “obvious to carers and nurses that Mrs Cole required one-to-one 24-hour care, but it was not provided”.

She concluded Mrs Cole died from an accident as a result of neglect.

Mrs Cole received one-to-one care from 11am until 11pm each day, and would regularly wake up in the night to wander the corridors despite staff at the home knowing that she was at significant risk of falls.

When she arrived at Rowan House in October 2015, Rowena Martin, then head of care at the home, said she had concerns that nurses were not keeping residents' care plans updated.

At the time of Mrs Cole's death, she added, there hadn't been any policy in place for the head of care to be made aware of residents' falls.

Ms Saunders asked about Andrea Din, a nurse who said she was not confident with updating care plans.

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(Mrs Cole (centre) surrounded by her family.)

Mrs Martin said she "had no doubts" that Ms Din "had the knowledge and skills of a nurse", but her level of English meant she was not expected to update care reports.

“Nurses at the care home had told me not to worry about care plans because I was new,” Ms Din said, who joined the care home in October 2015 a few months after moving from Romania.

Lisa Cornish, interim manager at Rowan House in January 2016, said she realised care plans were five months out of date when doing an audit in October 2015, and held staff meetings to investigate.

Angela Powell, who headed an investigation conducted by Aneurin Bevan University Health Board in 2016, said it would be reasonable to expect that patients as vulnerable as Mrs Cole would have had their care plans updated once a month.

A spokesman for Summerhill Group said: “This is not the standard of care we aim to achieve. We are sorry for the distress caused to Mrs Cole’s family.

“We pride ourselves on continual learning and improvement, as there is always something we can do better.

“We have fully co-operated with the investigation and lesson-learning that has taken place in this case and have upgraded a number of systems as a result.

“These improvements are reflected in the most recent inspection report published by Care Inspectorate Wales, which confirms that Rowan House residents have their well-being promoted by staff who have a good understanding of their needs and that they are treated with dignity and respect.”

After the inquest, Mrs Cole’s son, Brian Cole, said: “We’re frustrated this has taken so long, and we’re disappointed with social services, the police and the health board who have let our mother down.

“We are pleased that the case has made a difference and that the care home are making changes, and we’d like to say a huge thank- you to Nevill Hall who did a wonderful job caring for mum.”