A CHELMSFORD care home has made changes after an elderly man with dementia got out and fell into the River Chelmer and drowned.

George Mason, 82, had been living in Admirals Reach nursing home in Ridgewell Avenue.

Mr Mason wandered out of the Bupa-run home between 7.10am and 8pm on October 19 last year, without being seen. At an inquest into his death, Coroner Eleanor McGann found 12 failures, among which were:

  • An ongoing failure to prevent Mr Mason from leaving the home between October 11 and October 19
  • A failure to provide one to one care for Mr Mason between October 11 and October 17 and on October 19
  • Failure to adhere to the risk assessment and care plan
  • A failure to update Mr Mason’s risk assessment following other escapes
  • A lack of security

Amanda Malin, Mr Mason’s only daughter, said: “Despite suffering from dementia my dad had a good quality of life and we enjoyed our time together.

"The lack of care by his home, a place we trusted, has robbed us of the opportunity to continue that time together. This was an avoidable death.

“I hope this inquest sends a message to residential care homes that they must do everything possible to uphold the safety, care and comfort of their residents.”

Julie Say, partner at law firm Hodge Jones & Allen, who represented the family, said: “The evidence revealed a catalogue of errors and failures that ultimately led to George Mason’s death.

“Two particular concerns were standards of security, and the failure to adequately observe a dementia patient who was clearly in need of close supervision. Managing wandering risk is a basic part of dementia care.”

In a statement, a spokesman for Admirals Reach said: “We work hard to balance our residents’ desire to be independent in their home with the need to be secure.

Our residents’ welfare is always our number one priority.

“We have made changes to our code operated entry doors, reviewed all care plan documentation, and strengthened our risk assessments to ensure we understand the needs of individual residents.

"The coroner is satisfied that the home has taken all appropriate action.

“This was a tragic accident and we would like to again send our condolences to Mr Mason’s family.”