An 89-year-old woman died after being assaulted by a violent dementia patient who had been left on an open hospital ward for three months because his care home could no longer care for him, an inquest has heard.
Caryl Ann Mclaren, from Clacton, died at Ipswich Hospital on January 11, 2021, after sustaining multiple fractures and injuries just one day before she was due to be discharged.
She had been admitted to the hospital on New Year's Day with shortness of breath.
Mrs Mclaren sustained the injuries after being physically assaulted in the toilets of the Grundisburgh Ward on January 5.
A statement from Dr Shazia Awais, consultant physician at Ipswich Hospital, read out at the inquest claimed nurses heard a "loud bang and [Mrs Mclaren] calling for help".
"A man was standing outside and she was on the floor.
"She had been pushing back as the patient kept trying to get in before losing her balance and falling to the floor".
Mrs Mclaren suffered multiple fractures and injuries and died six days later.
The man, referred to throughout the inquest as Mr X, was an elderly patient with advanced stage dementia who had been on the ward since October 15, 2020.
Despite having a toilet of his own, staff say Mr X did not recognise this and instead often chose to use the bathroom in question.
Mr X had come from a care home that could no longer provide appropriate care for his specific needs and, at the time of the incident, healthcare staff were attempting to organise a placement at another home.
Witness statements from nurses concurred that Mr X had a history of violent and aggressive behaviour towards both patients and staff during the months leading up to this incident.
One nurse saw the man slap another patient, while another detailed a physical assault after he had accused her of being a hotel owner charging him for two nights instead of one.
He had also often been seen wandering around the ward confused, agitated and aggressive.
Dr Dan Coates, who works in older people's services at Ipswich Hospital, had been caring for Mr X at the time of the assault.
"Mr X shows behavioural displays typical of dementia and some of that can be challenging," he said during the inquest.
"He is a very kind gentleman but he can become aggressive.
"This is usually a sign of frustration due to him not being able to go where he wants to.
"I have spoken to him about the incident and he has no recollection.
"He would not be able to understand or rationalise his behaviour."
Family members of Mrs Mclaren said they believe there were missed opportunities to intervene and prevent the assault.
It is understood the complex care team at the hospital had requested the ward carry out a mental health assessment prior to the incident - but this was only completed after Mrs Mclaren had been assaulted.
A patient safety investigation report found that, had there been a formal risk assessment of aggressive behaviours, formal referral to a dementia specialist, increased level of staffing and a mental health referral, then the incident could have been prevented on the balance of probabilities.
A statement from the family described Mrs Mclaren as the "most loving, kindest, caring person and she was loved by all".
"We spoke with her beforehand and she was happy.
"She said she was feeling great and couldn't wait to come home.
"She suffered horrendously at the end and this has left us devastated, shocked and heatbroken."
The inquest shall reconvene on June 6.
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