A vulnerable man died at a south west London care home after being "stamped on" by another resident with dementia.

Neil Sweetmore, 86, was attacked by John Edgar on the day he returned from hospital to Viera Gray House, in Barnes, run by Greensleeves Care, following another alleged assault 18 days before in 2020.

An inquest at West London Coroner's Court, being held over three days this week, heard Mr Edgar had allegedly attacked Mr Sweetmore twice before the final incident on August 25, 2020.

Mr Edgar, who has since died, was said to have shown escalating violence and aggression towards staff as his dementia became more advanced.

The two men, who both had dementia, lived in rooms opposite each other until Mr Sweetmore returned from hospital on the day of the final attack.

He was moved to the same unit as Mr Edgar's wife, who Mr Edgar regularly visited.

On his return to the home, Mr Sweetmore was reported as having said: "I don't want to stay here. I'm going to die today."

A statement from a paramedic who took Mr Sweetmore to hospital that evening, after he was attacked by Mr Edgar, said he had received "several stamps to the face, chest and abdomen… I was told the duration of the incident was about five minutes long".

The post-mortem report concluded Mr Sweetmore died of pneumonia on September 11, 2020, which he had developed after an operation on a head injury. He had also suffered unwitnessed falls in the home.

Staff recorded concerns about Mr Edgar's behaviour from mid-April 2020, the month after he joined Viera Gray, the inquest heard.

He was said to be a "lovely man" and loving husband to his wife, who was in the later stages of dementia, but very territorial over her, which led to difficulties with carers due to his own dementia.

The inquest heard there were six incidents involving Mr Edgar in April and May 2020, including aggression and violence towards staff.

He threw a small heater at a female resident before slapping, punching and trying to strangle a carer on 12 July, and slapped a carer on 15 July.

Mr Sweetmore was described as a "wonderful man, very gentle and sociable".

With a passion for theatre, film and ballet, he starred in stage shows across the country before working in the BBC's costume department until 2013. His partner of 40 years died in 2015.

In July 2020, Mr Sweetmore joined Viera Gray and was placed in a room opposite Mr Edgar.

The court was told Mr Sweetmore often wandered into residents' rooms due to his dementia, which agitated Mr Edgar.

Statements from former staff claimed Mr Edgar had taken a dislike to Mr Sweetmore, and the inquest heard staff had told management he had made homophobic remarks about him.

Mr Edgar allegedly first hit Mr Sweetmore on 16 July, 2020. He was found distressed with a scratched elbow and dried blood in his ear.

The incident was not reported to the Care Quality Commission (CQC) or Richmond Council's Adult Social Services, as it should have been.

Mr Sweetmore had three unwitnessed falls from 23 July to 4 August.

In another unwitnessed incident on 7 August, Mr Edgar allegedly punched Mr Sweetmore in a corridor, causing a cut above his eye, after he went into his room.

Mr Sweetmore suffered an unwitnessed fall later that evening and was taken to hospital, where he stayed until 25 August.

An email from Mr Edgar's family to the home on August 10 raised concerns he was still waiting to receive a new prescription of antipsychotics to ease the symptoms of his advancing dementia. It asked for advice on moving him to a psychiatric hospital, the inquest heard.

The email stated: "We're really concerned the next time may be far worse than the last two incidents… we are very concerned for everyone else's safety."

West London Coroner's Court (credit: Google Maps).

'Entirely preventable'

Mr Edgar received the medication on 23 August. When Mr Sweetmore returned to Viera Gray on 25 August, he was taken to the Wren unit for residents with advanced dementia. Mr Edgar was said to be in the lounge of the unit.

Three carers were assigned to the unit, who were busy at the time of the incident that evening, along with a senior carer, who had left the floor.

A carer heard screaming and discovered Mr Edgar kicking Mr Sweetmore on the floor of the corridor.

She rang the emergency call bell but nobody answered, the inquest heard, forcing her to go downstairs to alert senior staff.

CT scans showed evidence of old and recent bleeding near Mr Sweetmore's brain consistent with the alleged assaults of 7 and 25 August, the court was told.

Doctors operated on his head injury but he developed severe pneumonia and died on 11 September.

Mr Edgar was sectioned and taken to a psychiatric hospital, where it was later reported he had settled.

A former carer said in a statement she believed Mr Edgar's final assault on Mr Sweetmore was "entirely preventable", had all staff been briefed when he returned from hospital and consulted on the best course of action.

Eleanor Watson-West, the Registered Manager of Viera Gray until she left in 2022, told the inquest she and supporting agencies had agreed moving Mr Sweetmore to the Wren unit was "the best decision to make", given there were no other empty rooms and there would be more staff to supervise him.

A former carer claimed in a statement she had warned Ms Watson-West that Mr Sweetmore would not be safer on the Wren unit as Mr Edgar visited his wife there, but that she told her there was nowhere else for him to go.

Ms Watson-West said she had reached out to different parties for more support with Mr Edgar before Mr Sweetmore's death, including mental health services, but "I felt like I wasn't really getting the support that I needed, that I wasn't really being listened to".

She urgently referred Mr Edgar to the community mental health team on 16 July, but they did not visit until 31 July.

Ms Watson-West said risk assessments and care plans for Mr Edgar were put in place and reviewed after incidents, and were deemed sufficient by supporting agencies.

"I feel I did everything in my power to try and support both [Mr Edgar and Mr Sweetmore] and my team," she told the court.

When asked by Coroner Lydia Brown about a "lack of joined-up knowledge and information" on incidents involving Mr Edgar at the home, Shona King, Divisional Director at Greensleeves Care, said staff were aware of his behaviour and incidents were appropriately investigated.

Ms King noted later investigations found "there needed to be much greater communication between all parties".

Claire McMahon, Assistant Service Manager for Richmond Council at the time, told the inquest Viera Gray did not notify Adult Social Services of Mr Edgar's violent and aggressive behaviour in April and May, which would have helped to map out his escalating risk.

She said the home did not inform the authority of Mr Edgar's first alleged assault of Mr Sweetmore on 16 July, or of his discharge from hospital on 25 August.

Ms McMahon said a multi-agency planning meeting to discuss Mr Sweetmore's safeguarding and set actions was not held until after his death, which was "one of the biggest learnings" the authority had taken forward. She added: "We just didn't see the bigger picture of risk."

The two-day live evidence portion of the inquest has now concluded, with the coroner handing down her findings yesterday (4 September).

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