Gravesend Community Hospital - also below

by Alan Watkins

“One minute he was there – then he was gone.”

These were the chilling words that described how an elderly resident in a Kent County Council-run home plummeted to his death from a secure unit for dementia patients.

Stanley Simmons, of Oak Drive, Higham, had been admitted to the Opal Two unit at Gravesham Place, part of Gravesend community hospital, on November 1 last year after his wife was taken ill.

Four days later the 87-year-old retired factory manager climbed over a balcony balustrade and fell three floors to his death as care staff in the unit sought help.

He suffered multiple injuries.

Coroner Roger Hatch told an inquest jury in Gravesend this week: “You may find it surprising that an 87-year-old man was able to climb that balcony, but we have heard he had no problems with mobility.

“It may be possible he was attempting to leave because he was anxious about his wife.

“We shall never know, of course.”

The jury decided his death was misadventure.

Staff told how Mr Simmons had disturbed them as they were writing his care programme in the unit’s dining area.

They found him on the balustrade.

Christine Johnson, one of the carers, said: “I saw Mr Simmons hanging on the other side of the balcony.

“My colleague ran round to get some help. I took a second look and he had gone. I just shouted out in shock.”

Peter Ward was visiting his own wife at the hospital.

He heard the shout from the balcony as he was walking nearby. He then saw Mr Simmons lying on the grass at the foot of the building.

He told the inquest he had expressed concerns about the open balconies, fearing for his wife.

Several witnesses told the jury it was normal for the doors between the lounge, dining area and balcony to be kept open all day, even in November.

This was because the clients’ communal rooms got very hot.

Care staff said they kept an eye on all clients when on the balcony, but a closer watch on any who were distressed or troubled.

That afternoon staff had noted Mr Simmons was anxious, but they had not seen him go to the balcony.

Peter Widdowson from the Health and Safety Executive said the area had since been altered and met the latest health and safety standards.

The Care Quality Commission had criticised the Opal units the previous month.

They had called for enough staff on duty to keep people safe and meet their health and welfare needs.

Four days after Mr Simmons’ death they carried out a spot inspection.

By then, the Opal units had sufficient staff for meeting care needs, but not enough leaders taking charge, or sufficient staff to provide residents with activities, said the commission.