An 85-year-old advanced dementia patient got out of an Angus care home through an unalarmed fire exit in the early hours of a winter morning, before catching hypothermia and dying.
Georgina Norrie left St Davids Care Home in Forfar, unnoticed and in just her nightie, between 2am and 6am on January 12 2017.
She had learning difficulties, advanced dementia, diabetes, chronic renal disease and a habit of getting up in the night to look for food.
Tape had been placed over the motion sensor in Ms Norrie’s room to disable it because she regularly activated it by her rolling over in bed.
After staff found her room empty during a routine check, they discovered her lying in the garden, rubbing herself to get warm.
Ms Norrie had been locked out. She was carried inside, freezing and wet.
After finding a certificate asking that CPR not be performed, staff ceased the procedure.
Paramedics declared Ms Norrie dead when they arrived.
She had lived at the Glamis Road home for 11 years and was described as being a well-known resident.
Care Inspectors had visited the Forfar premises – which went on to attract massive praise during the Covid crisis – just two months before the death and scored it as excellent.
The company was fined £100,000 at Dundee Sheriff Court after admitting breaching health and safety legislation.
Vulnerable woman leaves room
Fiscal depute Trina Sinclair told the court staff conducted routine checks of residents in their rooms at 10pm, 2am and 6am.
Ms Norrie was in bed at 2am but missing four hours later.
Neither the home nor its surrounds were covered by CCTV but the gates were chained shut and the walls were too high for residents to climb.
The search found Ms Norrie in the grounds but she later died.
A post-mortem four days later showed she died from hypothermia and atherosclerotic coronary artery disease.
Both carers working that night confirmed Ms Norrie got up “several times a night” looking for food – something she was allowed to do.
Of the care home’s six doors, five were alarmed.
Only the dining room, which opened onto a patio at which residents ate when it was warm, was not alarmed.
The court heard Ms Norrie rarely went outside, finding it cold even in the summer.
Defence advocate Wendy Culross said: “She was known to wander but was doing so less and had not wandered at night for a little bit of time.
“In general, she did not like to go outside.
“Her behaviour certainly was out of character.”
Owner self-reported to HSE
The care home has been run by Ivan and Lisa Cornford since 2006. Both have a background in nursing.
On Friday, their firm admitted failing to provide effective arrangements to prevent residents from leaving the care home unnoticed, without alerting staff to their movements.
Despite the incident happening more than six years ago, the hearing was the earliest opportunity the company could plead guilty.
Doing so meant the fine was reduced by £50,000.
Ms Culross said: “The incident is now of some age.
“The company has at all times been keen to resolve the case.
“Mr Cornford reported the incident to the Health and Safety Executive on January 13 (2017).
“From my initial consultation, the company has fully accepted that an error was made here in relation to the alarm on the door.
“The risk of the particular door not being alarmed is accepted as a failure.”
Record praised
An alarm was fitted on the fire door “very soon” after the incident and its use has since stopped altogether, Ms Culross confirmed.
She said bosses were allowed to disable Ms Norrie’s bedroom motion sensor.
The sensors have been replaced and moved to “optimum” locations.
“This is not a secure unit. A care home is not permitted to lock residents in.
“Residents can go to bed when they want and get up when they want.”
Nothing similar has happened since at St Davids and the home has continued to be scored highly by inspectors.
The company’s lawyer added the breach did not stem from financially-motivated actions.
“This was, while absolutely a very serious and very distressing incident, one that was isolated.
“It was only one resident who was involved in the case.
“There is an excellent health and safety record prior to this incident and since.
“There was no greater risk to the public.”
Owners left ‘devastated’
St Davids Care Home has space for 24 residents and currently has 22. It employs 37 staff.
The court heard its facilities have been split into those with higher dementia needs and lower needs, since the incident.
Last year, the home scored in Scotland’s top ten in a league table compiled by The Times.
Ms Culross said it had built a reputation for excellence during the pandemic when a director and 11 employees moved in for a month to minimise Covid-19 risk.
They affectionately became known as the St Davids 12.
She said no residents caught coronavirus until January 2022, when everyone had had vaccinations and boosters and no residents had died of the disease.
“The directors have lived with this case hanging over them and what is to them their family for the last six years, and felt significant remorse.
“That is something that has struck me every time I have consulted.
“The directors have been devastated by this incident. The one thing the directors have asked me to express is their significant regret.”
Condolences from sheriff
Ms Culross said although a fine was inevitable, it would have an impact on residents, and pointed out how extensively the home’s bills had risen recently.
Sentencing, Sheriff Gregor Murray pointed out the firm had had six years to prepare for the penalty.
They will pay the six-figure sum at £1,500 per month.
He expressed his condolences to Ms Norrie’s friends and family and noted the home’s “excellent reputation”.
Debbie Carroll leads on health and safety investigations for the Crown Office and Procurator Fiscal Service (COPFS).
She said: “The death of this vulnerable woman could have been prevented if St Davids Care Forfar Ltd had taken the reasonably practicable preventative measure of having the fire door alarmed.
“Their failure to have sufficient controls in place to manage this significant risk meant that staff were unaware that a resident had left the building on a cold January night and led to the death of Georgina Norrie.
“This prosecution serves to highlight the need for all care homes to protect their residents and remind them they will be held accountable if they fail to do so.”
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