Richmond: Family says care home failings led to grandma’s tragic death after fall
A much-loved grandma broke her neck and died in a south west London care home because it failed to keep her safe, her daughter has said.
Paula Geeves-Booth, 93, was found dead on the floor at Viera Gray House, in Barnes, run by Greensleeves Care, after falling from her bed on June 16, 2022.
Paula's daughter, Sarah Booth, 64, said staff were aware of the danger she faced before she died as she had fallen from her bed in similar circumstances that March.
She was also found injured on the floor in November 2021, after falling from her chair, as she had not been helped to bed.
Despite this, the coroner found staff were not alerted to Paula's fatal fall on June 16, 2022, as her sensor mat had been unplugged and there was no alternative emergency alarm or staff check between 7.40am, when she was last seen asleep, and 9.14am.
The coroner's report in October 2024, which ruled her death was an accident, said she fell at some point between these times, likely from a sitting position, which fractured her neck in two places.
Sarah had raised concerns to the home about her mum's mat often being unplugged just two days before she died.
Sarah believes her mum's traumatic death, and the two falls leading up to it, were preventable.
She said poor management of Viera Gray House resulted in her mum receiving inadequate care, with the Care Quality Commission (CQC) finding a catalogue of failings at the home just months after her death.
Sarah told the Local Democracy Reporting Service (LDRS): "Three awful falls she had. All of those falls could have been prevented. It happened because there were significant failings in that care home and my mother died as a result of it."
She added: "There's no reason why my mother couldn't have passed peacefully in her bed with me and her family around her, no reason other than their failure to keep her safe."
Viera Gray House apologised for not meeting Sarah's expectations regarding its handling of her mum's case, and said it has since addressed shortcomings identified by the CQC and introduced new management at the home.
It has paid Paula's estate damages over her death.
Sarah described her mum, a loving grandma and great-grandma, as 'simply beautiful in every way'.
She moved into Viera Gray House around 2018 when she could no longer live safely at home, as she was losing her sight and had become scared at night.
Sarah increasingly complained to the home about her mum's care as she began deteriorating during the Covid-19 pandemic.
She claimed staff often did not answer her mum's call bell, which left her searching the home for somebody to help.
Sarah submitted a formal complaint after her mum developed severe bruising and a hematoma on her leg when she fell from her chair on the night of November 23, 2021, as she had not been helped to bed.
She was discovered injured again on March 28, 2022, after falling out of bed and landing heavily on her face. She was left with facial wounds, a bruised nose and neck pain.
Although Paula was shaken up by these falls, she appeared fine when Sarah visited her on June 15.
She was horrified to be told by the home's registered manager less than a day later, on the morning of June 16, that her mum had died.
Sarah rushed to the home to find her mum cleaned up and in bed, despite neither emergency services nor a GP having arrived, with a wound above her eye and severe facial bruising.
She said there were bloody gloves in the bin and her sensor mat, to alert staff to falls, was missing.
Sarah was immediately concerned as she claims the manager was not forthcoming with information and she could not speak to carers present on the day.
The following years felt like a circus as she searched for answers about her mum's death, she said, and came up against a 'wall of silence' from the home.
"It was just an absolute mess," Sarah said. "I don't know how I survived physically, emotionally, spiritually. I was absolutely on the abyss."
The CQC had already rated Viera Gray House as 'Requires Improvement' for safety in October 2021, eight months before Paula died.
Inspectors visited partly due to concerns about staffing levels, risk management and an incident which had resulted in another resident's death.
They found residents' risk management plans did not always give staff clear guidance on how to keep people safe from harm.
A year later, after a reinspection in October 2022, partly in response to Paula's death, the CQC published a damning report cataloguing failures around people's safety and management of the home.
It slapped the home with the worst possible rating of 'Inadequate' and placed it in special measures.
Inspectors found residents were not protected from the risk of harm and abuse, there were not enough staff to keep residents safe, incidents were not always recorded or managed effectively and lessons were not always learned when things went wrong. They described a closed culture whereby staff were not always confident in speaking out against poor practice.
Richmond and Wandsworth Safeguarding Adults Board published a report, in January 2023, which found Paula had experienced neglect as staff failed to follow her support plan.
It said staff lacked transparency during enquiries and appeared to have decided to omit that her sensor mat had been unplugged the night before she died.
The report revealed a motion sensor to detect Paula's movement in bed had also been trialled, and would have recorded when she sat up, but it was not attached at the time of her death as staff were not trained in how to use it.
Staff failed to follow policy when they put her back in bed when she was found deceased, it added, as a person who dies in unexpected circumstances should not be moved until they are seen by a GP.
The report added that while a cyber attack meant key records relating to Paula's death were lost, the manager had already been asked for this information several times.
The LDRS understands the manager left the home soon after Paula's death, before the CQC inspection.
Sarah still does not have answers to key questions about her mum's death, including what happened to the call bell she should have been wearing when she fell.
"Mum was in a supposed safe place where the answers are available and I haven't had them," she said. "That's not right."
Sarah said she has been let down by the 'broken' care sector as staff at Viera Gray House have not been held accountable for failings in relation to her mum's care.
She believes the CQC has shown itself to be ineffective in supporting families as it does not have the power to take enforcement action against individual workers.
She wants every care worker to be required to register with the CQC to ensure they meet safety standards, as she called for better safety, transparency and accountability in care homes so residents' lives are valued.
Sarah told the LDRS: "Our mother was wonderful. She lived a long, full and colourful life. She was deeply loved by her family, friends, her husband, four children, five grandchildren and three great-grandchildren. We could not have wished for more.
"I will have to try and come to terms with never fully knowing what happened to our lovely mum on that day, it's a heavy weight to bear. To lose such a precious person in such an awful, preventable way is soul-destroying and has brought with it pain that I never imagined I could endure.
"To have to battle for answers and accountability, to discover that there are no means by which individual staff can be held accountable for their actions, on top of grieving such a tremendous loss is overwhelmingly painful, but the love I had for my mother, and the love she so freely gave to all of us, this love has helped me survive.
"Moving forward as a family, we will not focus on the last awful hours and moments of her death. In our hearts we will carry her as far away from that place as we can. Instead, we will rejoice in the full life she lived, the love and support she gave and the many wonderful years that we all spent together."
A Viera Gray House spokesperson said: "The team at Viera Gray House offer our deepest condolences to the family and friends of Ms Geeves-Booth.
"The safety of those we support is our number one priority and we worked cooperatively with the authorities throughout investigations, which were completed in October 2024 with the coroner's conclusion of accidental death.
"We fully accepted the findings following CQC inspections and addressed the shortcomings. We have new management and strong support in place, and we welcome ongoing scrutiny to ensure we continue to provide safe and high-quality care to all those we support.
"Throughout, we have strived to communicate openly and compassionately, and are truly sorry that we did not meet the expectations of Ms Geeves-Booth's daughter.
"We are committed to learning and improving, and our thoughts remain with the family and friends following this very tragic loss."
A CQC spokesperson said: "Our condolences remain with the loved ones of Paula Geeves-Booth, following her death in June 2022.
"Following concerns raised with us about the circumstances of her death, we inspected Viera Gray House in October 2022 and confirmed serious breaches of regulation around people's safety and the management of the home.
"As a result, we rated the home Inadequate, put them into special measures and placed conditions on the home's registration to restrict new admissions and require monthly updates to CQC on the progress of urgent improvements to keep people safe.
"We shared the information we held with the local safeguarding team, police, and coroner as part of their investigations.
"We also carried out an investigation into whether there was evidence beyond a reasonable doubt of a provider level failure to protect Paula Geeves-Booth from avoidable harm.
"After a thorough review of all the evidence we did not find sufficient evidence of provider level failure to give grounds to pursue prosecution.
"CQC has legal powers to prosecute provider level failings but does not have legal powers to prosecute failures by individual workers.
"We understand this is disappointing for Paula's family and spoke with them at the time to help them understand our decision.
"Viera Gray House is now rated Requires Improvement after CQC found some improvements in April 2023.
"However, conditions placed on the home's registration in October 2022 remain in place and the home is being monitored closely to keep people safe while improvements are made."
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