The death of a resident who fell at a Sheppey care home was an accident, a coroner has ruled.

Terry Raymond, 41, who had learning difficulties, fell at the Little Oyster care home at Minster on February 7, last year while on a video call to his mother, an inquest at County Hall, Maidstone, heard.

An ambulance was called and Mr Raymond was taken to Medway Maritime Hospital, Gillingham.

Doctors could not find any serious injury at first, except for a graze to his head, and suspected he may have suffered a stroke. But a CT scan later found bleeding on his brain which was referred to as a non-survivable "catastrophic" head injury.

He died in the early hours of the following morning with his family at his bedside.

Doctors put the cause down to the genetic wasting disease myotonic dystrophy which made him prone to falls.

His sister Tarnia Harrison said: "As a family, we are lost for words and considering our options. We are still grieving for Terry."

She said she was "very frustrated" and "disappointed" at the finding. She had previously raised concerns about the standard of care at the home.

The inquest concluded on Tuesday, May 10, after four days' of evidence.

Assistant coroner James Dilllon gave the cause of death as an intracranial haemorrhage.

He said: "I find the fall which Terry suffered and led to the fatal head injury was, on the balance of probabilities, associated with his myotonic dystrophy."

He said he could not find any evidence of neglect by staff at the home and added that issues raised by the family about documentation, note-taking, training and the home's falls policy had no link to Mr Raymond's death.

He went on: "Terry had been assessed as having capacity to make his own decisions, which included not wanting assistance. I cannot find any action, inaction or omission by Little Oyster, as far as Terry being able to get up in his room unsupervised, was a factor.

"No evidence was presented that there was anything inherently dangerous in Terry's room, nor a specific hazard to him such as anything he may have tripped over."

The inquest heard that Mr Raymond had suffered from myotonic dystrophy, sometimes known as Steinhert disease, for eight years.

He was sent to the Little Oyster for assessment on September 10, 2020, after being taken to hospital with a broken toe following a fall at his flat on August 26, and remained at the home on The Leas until his death.

The court heard that during his time there, he suffered seven falls.

* He had an unwitnessed fall in his bedroom at 7.20am on September 11.

* He fell from a chair in the conservatory at noon on October 13.

* He hit his head in a fall in the annex office on October 25.

* He fell in his room and bumped his head on December 7.

* He injured his ankle after tripping over a table leg on January 1, 2021 at 1.30pm.

On the fateful day of February 2 he fell twice, both in his room.

The first was at 1.45pm and unwitnessed. Staff said no injuries were found and no ambulance was called.

The second was around 3.45pm during a Zoom video call with his mother Marion Hammett.

Staff said Mr Raymond had been unconscious for 10 minutes and had then tried to get up.

They called 999 and an ambulance arrived at 4.17pm. Paramedics took him to hospital.

In October 2021 the Care Quality Commission (CQC) changed its previous rating for the home from 'good' to 'inadequate' following an unannounced inspection by a team of four in July and placed it in special measures because of insufficient staffing, unsafe medicine management and a cleanliness risk to infection control.

The report said residents were not always safe. Comments included: “I feel unsafe here because of the staffing levels” and "I feel very unsafe - I can’t sleep or settle.”

Inspectors said: "The provider had not developed an open and honest culture where staff were empowered to raise any safeguarding concerns. People were not protected from harm and abuse."

They added: "People were not always treated with dignity and respect. Personal records were not always stored securely to ensure they were only accessible to those authorised to view them."

The hearing was told in January this year the CQC had proposed to cancel the home's registration but had since withdrawn it. A further inspection was carried out in February.

A spokesman for the home, which is run by Little Oyster Ltd, said: “We again offer our condolences to Mr Raymond’s family; we were all saddened by his death.

"We have, at all times, fully supported all inquiries concerning his death and cooperated fully with the inquest. We accept the conclusions given by the coroner that this was an accident, that there was no evidence of neglect in the care that we provided for Mr Raymond.

"Separately we have worked closely with the CQC on the recommendations they made about the operation of Little Oyster and following significant changes and expansion in staffing at the home we continue to improve the service provision. The special measures notification has been lifted and we continue to work with the CQC on the implementation our improvement plans.”