AN INQUEST has slammed a care home for a series of communication blunders leading up to the death of an 88-year-old woman.


Mary Bouweraerts died from a brain injury and pneumonia after hitting her head at Ashgreen House in Woolwich where she was recovering from a hip operation.


However Southwark Coroners Court was told the pensioner, who lived in Sunnydale Road, Lee, was not taken to hospital or even examined by a doctor following the fall.


Nurses at the home, which is run by Sanctuary Care, said they were unable to contact the on-call doctor as the line was engaged - and did not send the patient to hospital as she appeared unwilling.


But Coroner Andrew Harris told on-duty nurse Christine Downer: "What I’m struggling to understand is why you didn’t get help or speak to anyone senior in the home to make sure?


"Did you know that anti-coagulates puts her at a higher risk of having bleeds if she fell?


"You only need the tiniest knock at this age.


"Wouldn’t that make it more urgent to get medical help?"


Ms Downer said there was no clear policy for sending patients to hospital after a tumble and it was up to the nurse’s clinical judgement.


She told the court Mrs Bouweraerts appeared well after the fall and was anxious not to go to hospital.


Ms Downer said: "The physio thought we should send her to hospital. I said I wasn’t that concerned at that point but I asked the patient whether she would want to go - she refused.


"I considered the overriding decision should lie with the patient."


Mrs Bouweraerts’ daughter, Johanna Thorne, says she was not told of the gravity of the situation and would have persuaded her mother to go to hospital if she had known.


The 62-year-old said: "At no point was I made aware of any risk whatsoever leading to a brain injury.


"If I had done we would have behaved quite differently.


"Also to talk about mum refusing hospital. She was a very amenable person and if I or my brother had spoken to her we would have easily been able to persuade her."


The coroner gave a verdict of accidental death but noted failures in the management system and a need to clarify guidelines for nurses.


He ruled it was unclear whether medical treatment would have prevented Mrs Bouweraerts’ death.


Dr Harris said: "I can’t find a neglect verdict. It doesn’t minimise the failures that were here but the law is very specific and requires serious or gross failure."


He told the family: "Of course that won’t bring Mary back but perhaps the inquest will help you turn a page in the book of your lives."

Family unhappy with the verdict

Mrs Bouweraerts’ family were very unhappy with the verdict and are considering retrospectively taking legal action.


Johanna Thorne said: "'We had every reason to expect a neglect verdict.


"I wanted Sanctuary Care to be publicly shamed and severely reprimanded.


"Their policies and procedures are hopelessly inadequate and leave all responsibility on the nurses' shoulders with no support from management.


"Nothing was said that made me feel things would change because they did not truly accept their failings."


Since Mary passed away on April 20 last year Sanctuary Care have tightened their policies surrounding such accidents and management are required to dial 999 if a serious fall is suspected.

Tribute to Mary Bouweraerts
The grandmother-of-two from Lee was a "lovely" "funny" woman with a large extended family and friends.


The retired primary school teacher enjoyed embroidery and gossiping with friends at the Community Centre in Eltham.


Her daughter Johanna Thorne, who lives in Blackheath, said: "She was a lovely woman. She was very well liked with a very large family. 


Mrs Bouweraerts had joked about her "shiner" in the care home following her fall.


Mrs Thorne said: "That was typical for her. She has left a big gap in everyone’s lives."