A care home in Tenbury Wells has been given eight weeks to make changes after pensioner's death

Senior coroner David Reid said he had concerns further lives could be at risk at Haresbrook Park care home in Tenbury Wells after the death of Margaet Medlicott from Hereford.

He has issued a prevention of future deaths report around the culture and training at the care home, owned by Shrewsbury-based Capital Care Group.

Grandmother of three Mrs Medlicott, aged 77, died at The County Hospital, Hereford in May 2020, 10 days after being deliberately pushed over by another resident and sustaining a serious head injury at Haresbrook Park. Both Mrs Medlicott and the resident who pushed her had advanced dementia.

Now the coroner has sent a 'prevention of future deaths' report to the chief executive officer of Capital Care Group.

It highlights that the decision to admit the resident who pushed Mrs Medlicott was made by a senior manager without the clinical qualifications needed to assess whether his needs could be met at Haresbrook Park and despite having concerns, no care home staff felt able to raise or question the decision to admit the resident with senior management.

It also found staff working at Haresbrook Park may not have understood their professional duty to question such a decision and the care home was not providing a working environment which encourages staff with concerns to raise them.

The report also concluded staff failed to complete proper risk assessments and care plans for Mrs Medlicott and the resident who pushed her and they may not have received proper training in how to carry out risk assessments and care plans.

Mrs Medlicott's daughter Karen Rosser said: “As a family we are grateful to the coroner for rightly raising concerns about the culture and practices at Haresbrook Park – they lead from the very top of the care home’s management, to the frontline staff who felt they could not speak up.

“I also agree that the admissions of my mother and the resident who pushed her were the result of a culture at the care home which was not prioritising patient safety. The inquest heard that they were accepted at a time Haresbrook Park was under immense financial pressure.

“For the current residents at Haresbrook Park and those at other Capital Care Group homes I hope that the coroner’s concerns are treated with the seriousness they deserve and are acted upon so that no other family has to go through what we have."

Caleb Bawdon, for solicitors Leigh Day who represented the family, said: "From a private care operator under financial strain to a culture where professional duties were disregarded, the inquest into much loved Margaret’s death has highlighted issues which should be of note to the entire care sector.

“Margaret died because she was in a care home into which she should never have been admitted, and the coroner has been clear that without changes the lives and safety of other residents could be at risk.”

Haresbrook Park care home has been contacted for comment.