A VULNERABLE elderly woman suffering from advanced dementia fell 12 times during a short stay in a care home, leading to her death.

Gladys Goodrick died in hospital in January 2016 after suffering serious injuries following numerous falls during her stay in North Park Care Centre, Darlington, which is rated “good” by the Care Quality Commission.

A safeguarding review published this week recommended that communication needed to improve between professionals caring for the elderly, and concerns were raised that a robust care assessment was not carried out by social services, because Mrs Goodrick’s family had indicated they would be self-funding.

However, the report also concluded that 86-year-old Mrs Goodrick was at such an advanced stage of dementia that it was difficult to prevent her falling.

She was admitted to Darlington Memorial Hospital last January suffering from broken ribs, a punctured lung and a slight bleed on the brain, after the numerous falls, and she was put on end of life care 17 days before her death of natural causes on January 31.

Darlington Safeguarding Adults Partnership Board carried out its Safeguarding Adult Review to understand how different agencies worked together in the run-up to Mrs Goodrick’s death.

The review found that information sharing between professionals and processes for the assessment of adults with care and support needs on admission to care home settings in emergency situations needs to be made more robust.

It also found that the home was not informed of how advanced her dementia was, and initially was placed on a unit which did not manage dementia. Even when she became a permanent resident, however, “her needs were not comprehensively assessed”. There should have been a more robust reaction to her repeated falls, it concluded.

Several failings were found, including lack of communication by the GP not updating an electronic system, the community matrons not having a good history of the falls from care home staff, and confusion about what assessments had been carried out.

After Mrs Goodrick’s death an immediate “critical incident review” was carried out within the care home, which had led to changes in recording falls and other improvements.

Ann Baxter, independent chair of the Darlington Safeguarding Adults Partnership Board, said: “This is a very sad death and our thoughts are with the family who have lost a loved one.

“They have been included throughout this process, and we thank them for their involvement at a very difficult time.

“There has been significant learning from this review for all the organisations involved.

"Eight recommendations were made and the Board will monitor the subsequent action plan to ensure that changes are implemented.”

A verdict of natural causes was recorded at an earlier inquest into Mrs Goodrick’s death.