St Cross Grange manager told staff not to call ambulance for dying pensioner

An inquest heard how Ella Davidson, 94, was found choking on a piece of grapefruit by staff at the St Cross Grange residential care home. They immediately summoned manager Anne Taylor but when she arrived Mrs Taylor simply checked Mrs Davidson’s pulse before dismissing the idea of calling the emergency services and making no attempts at resuscitation.

Coroner Grahame Short said the failure to call an ambulance to the Winchester care home made Mrs Davidson’s death inevitable.

Staff member Veronica Westcott, who discovered Mrs Davidson, told the inquest she watched as the pensioner took her final breaths.

The carer, giving evidence at Winchester Coroner’s Court said she had felt unqualified to help the pensioner, so raised the alarm.

She said: “Somebody came in and said: ‘Shall we call an ambulance?’ She (Mrs Taylor) said: ‘No, she’ll be dead by the time they arrive. She left the room and I was left there to watch her die.

“She [Mrs Davidson] should not have been there, she should have been in hospital and there was nothing I could do to save her.”

Deputy manager Jim Russell and care assistant Toby Edwards also gave evidence, saying Mrs Taylor rejected pleas for the emergency services to be called.

Mrs Westcott said the pensioner – who suffered from Parkinson’s Disease – was still gasping for breath minutes later when staff moved her from her chair to her bed.

Asked if resuscitation would have saved the pensioner, expert witness Dr David Sutton told the inquest: “I think it’s possible but unlikely.

“From the pathologist’s report the obstruction was completely across the trachea (airway).

“But from what I have heard and read the obstruction was partial to start with and it is possible some air would have got past to the lungs. It’s possible it would have prolonged Ella Davidson’s life, long enough for the emergency services to arrive.”

A police-led investigation was launched after concerns were raised that no ambulance had been called as a result of the incident that happened in June last year.

Mrs Taylor, a former intensive care nurse, told investigating officers that Mrs Davidson’s breathing was “purposeless”.

Asked why she did not attempt resuscitation or call an ambulance, she told them: “I felt she had died.”

A Hampshire police spokesman said that as a result of the investigation it was decided there was not enough evidence to pursue a prosecution.

An internal investigation then followed by Greensleeves Homes Trust (GHT), which runs the home, resulted in Mrs Taylor being dismissed.

Grahame Short, coroner for central Hampshire, recording a verdict of accidental death, said it was a matter of conjecture as to whether resuscitation would have saved Mrs Davidson.

He added: “What we can say is that the failure to summon help and to take her to hospital meant her death was inevitable.”

"Deep Regrets"

A SPOKESMAN for Greensleeves Homes Trust said: “We deeply regret the distressing circumstances of Mrs Davidson’s death and offer our deepest condolences to her family.

“Following the conclusion of police inquiries and the decision that no one was to be charged with an offence, we carried out our own internal investigation, including a disciplinary inquiry, and Mrs Taylor was dismissed.

“We have reminded senior staff at all our homes that it is vital to call an ambulance in the case of sudden or unexpected collapse of a resident.

“Our investigation found that our policy on this matter was both understood and being followed in all our homes, so that this incident was a single aberration.

“We are confident that the requirement to call an ambulance in a case such as this is instinctive with all our managers and senior staff.”

A spokesman for Hampshire County Council, who were aware of the investigation as the local social services department, said: “This was a police-led safeguarding investigation and Greensleeves has acted in the manner they deem most appropriate. Police and Greensleeves were there to act – Hampshire County Council gave its support as appropriate.”