An inquest has heard that a vulnerable man with learning difficulties died after falling at his Minster care home and injuring his head.

Terry Raymond, 41, was taken to Medway Maritime Hospital on February 7 last year after falling at the Little Oyster residential home in Seaside Avenue.

A CT scan revealed that he had suffered a catastrophic brain injury that specialists at King's College Hospital in London, after reviewing the scans, said was "unsurvivable".

Mr Raymond was given palliative care and died in the early hours of the next day.

He had suffered a number of health problems.

Mr Raymond had a history of Steiners Disease that causes delayed development and reduced muscle tone.

He also had Aspergers Syndrome – a form of autism with which he was diagnosed in June 2004

He had learning difficulties and also suffered from a rare genetic condition called myotonic dystrophy – a muscle-wasting disease.

This led to poor breathing and he had to use a ventilation machine, especially at night.

The machine did not supply oxygen but rather room air delivered at pressure.

He could manage the machine during the day but not at night when he needed help to fit the mask, a task usually done by his mother or sister.

Mr Raymond came to end up at the Little Oyster Care Home after suffering a fall at his flat in Minster on August 26 when he had to be admitted to Medway Maritime Hospital.

When he was ready for discharge, both his consultant Dr Ahmed Haque and his relatives felt he couldn't return to living on his own.

Dr Haque decided that after treatment, Mr Raymond, who had had three falls in the previous four weeks, should be discharged to an "assessment bed" rather than discharged home.

Coroner James Dillon heard that an assessment bed was supposed to be one where the patient's care needs could be assessed for a period of up to six weeks, after which a determination would be made about the type of long-term care he needed.

Emily Challis, an assistant practitioner for Medway Community Health Integrated Discharge Team told the hearing at County Hall in Maidstone how she had tried to find Mr Raymond a bed at either Harty Ward at Sheppey Community Hospital in Minster or Kestrel Ward at Sittingbourne Memorial Hospital but Virgin Care which runs the wards said they were unable to take him because they had no-one trained to operate his night-time ventilation machine.

They couldn't allow family members into the ward to do it because of Covid restrictions.

So Mr Raymond was placed with Little Oyster, although Mrs Challis said she was not familiar with the level of care there.

Mr Raymond's sister Tarnia Harrison was unhappy about the placement from the outset and said the family had not been consulted. They only found out when her brother phoned them from the ambulance on the journey there.

She felt as a residential home rather than a nursing home, Little Oyster would not be able to properly look after her brother.

She was also not aware that any assessment of her brother's needs was carried out and said the six weeks had morphed into a four-and-a-half-month stay at Little Oyster until his death.

Miss Harrison described her brother as an avid churchgoer and bell ringer. When he had been living independently he had gone to an Age Concern Day Centre five times a week and had twice daily visits by KCC carers, as well regular daily visits by his mother and sister to maintain the ventilator.

She said: "I am concerned that the initial placement at Little Oyster was inappropriate and that no assessment was ever carried out."

Mr Raymond had sent the family several disturbing text messages, saying: "They hadn't done this or they hadn't done that." He had written in his diary: "I do not trust my carers."

He suffered a fall at the nursing home the day after his arrival and had seven in total at the home, including two on the last day.

The inquest heard that once a patient leaves the hospital, they become the responsibility of KCC adult social care.

Ann Lees Msichilli, a KCC safeguarding assistant, also gave evidence.

She had no dealing with Mr Raymond while he was alive but since the family had raised allegations of neglect she carried out an investigation after his death. Her report was made in two parts. An initial finding on June 22, 2021, and an updated report on November 22.

She said that when Mr Raymond had first been sent to the home it was under a scheme that used government Covid funding to finance his care.

She found there had been an assessment by an occupational therapist on October 9 which had concluded that Terry was not able to return home.

She said that his care plan was a "living document" that was continually updated but the family would not necessarily be involved every time.

On November 12, he was assessed for KCC funding as needing to be a long-term resident with a high level of care. She said: "This was the assessment happening."

'I am more or less happy here'

It was residential care, as opposed to nursing care, but recognition that he needed a high level of support.

On November 16, adult safeguarding staff had met Mr Raymond who told them the care he was being given was "not up to scratch".

One of his complaints was that his room had no window so his family could not talk to him from outside as other patients' families could do. Also the internet connection was poor.

He complained that the staff were slow to answer his call buzzer and that he was not showering or cleaning his teeth. However, he also said: "I am more or less happy here. The staff are nice."

On November 23 he was moved to a new room with a window and better internet and he perked up.

She found that his care and support plan had been reviewed by the home on January 21.

However, she also catalogued the series of falls. Mr Raymond had generally been treated by paramedics at the home and he had declined to go to hospital because he was frightened of catching Covid there.

Mrs Msichilli also reported on events subsequent to Mr Raymond's death.

Following complaints from his sister, the Care Quality Commission had investigated the home.

On March 21, the CQC said the home had failed to understand Mr Raymond's needs and had not carried out proper risk assessments. They served a warning notice on the home.

'An opportunity to learn from his falls had been lost'

However, on a subsequent visit on April 14, after the home had made improvements, the CQC changed its assessment from Requires Improvement to Good.

In her own investigation, Mrs Msischilli found that the home's care records for Mr Raymond were "disorganised and incomplete".

There was no record made of contacts with the family but curiously there was a record of staff helping Mr Raymond to clean his teeth on the evening of February 7 when he had already been admitted to hospital.

She found that although the care home had a policy about falls, it was not followed.

An assessment form should have been completed after every fall. It never was. She said: "That was a missed opportunity to learn from the falls that he had already had."

'The CQC has served a cancellation of registration order...'

As a result, KCC put a poor practice level 2 order on Little Oyster, which meant KCC would send it no new placements until it was satisfied the home had improved.

Mrs Msichilli then surprised the court by saying that just ahead of the inquest she had made inquiries to find out the up-to-date information about Little Oyster and had learnt that on January 20, CQC has served a proposed cancellation of registration order on the care home.

This was news even to the coroner.

On the second day of the inquest, Thierry LeMasonry, who is now an ambulance driver but was working at the Little Oyster as a Covid support technician and later a senior support worker, said she was called by a colleague who had found Terry face down on the floor of his room between 1.30pm and 2pm on the day of the fall.

Miss LeMasonry said: "I asked Terry how he was and he said he wasn't in any pain and hadn't hit his head. His trousers were below his body so we turned him over and pulled them up. I checked his face and neck and chest for any injuries.

"He told us many times an ambulance should not be called and as he had capacity we respected his wishes. He said he had been trying to pull his trousers up after visiting the toilet but didn't want any help. He was very independent. But he asked us to help him sit up."

Under questioning by Sefton Kwasnik for the family, she said she had not received any specific falls training but some advice was covered in her First Aid training.

Senior worker Leanne Maynard said she had been on her way to another resident at 1.45pm when a colleague called to say Terry was on the floor of his room.

She said he had another fall at 4pm and lost consciousness. She said: "We were unable to rouse him for more than a few minutes at a time."

An ambulance was called and took 30 to 40 minutes. Terry was wrapped in his duvet to keep warm. She said it was feared he had suffered a stroke as part of his face had fallen. She handed his medications to paramedics when they arrived.

She said she had received no special falls training but parts had been covered in her First Aid training.

Four other staff and the care home manager Natalie Bebbington are yet to be called. The inquest was adjourned to February 28.