The death of an 86-year-old pensioner who fell from a roof at her care home was a tragic accident, a coroner has ruled.

But the inquest had earlier heard evidence from Susan Skinner that in the view of KCC's Social Services safeguarding team the death had been avoidable and her department was conducting what is known as a Section 42 inquiry into the level of care provided by the Grosvenor Court Care Home in First Avenue, at Cliftonville, near Margate.

Jean Herring suffered from dementia, but she was described as "strong-minded" and she was fully mobile. She had lived at the home since July 2016.

On the evening of January 29, last year, she had rowed with another resident and subsequently had tried to leave the home, banging on the front door to be let out.

Staff tried to distract her by offering her tea, but at around 7.30pm she got into the lift to go up to her room on the fifth floor.

The exact time is not known, because the time clock on the home's CCTV was inaccurate.

The alarm sounded in the lift, but when staff went to see what was wrong, Mrs Herring was not there.

'I didn't know the door existed.'

Staff carried out a number of searches of the building over the next few hours, but could not find her. They believed she must be in the building, because all the fire doors were alarmed and if opened would have sounded an alarm.

Eventually police were called at 11.52pm. Officers found Mrs Herring's body in a yard between the main building and an extension.

DS Lewis Tompsett said that although officers attempted CPR, paramedics later declared Mrs Herring dead at the scene. He said her injuries were consistent with a fall from the roof and there was no suspicion of any third party involvement.

Coroner James Dillon heard that there had been a fire escape door leading onto the roof of the extension that had been decommissioned.

It still had a push-bar opening mechanism and fire exit signs above the door that had been covered over with parcel tape.

The door was only used for maintenance to access the roof of the extension and should have been kept locked by a magnetic lock that only allowed it to be opened by inserting the correct code into a keypad.

However, the wiring to the lock was faulty and the power had failed. There was a back-up battery, but this had eventually depleted, releasing the lock, which had allowed Mrs Herring to open the door.

Because it was no longer considered a fire exit, the door had not been wired into the alarm panel.

The care home's CCTV only covered three floors and had not shown the upper ground floor, from which Mrs Herring had fallen..

Once on the roof, there was a only a small thigh-high railing to prevent anyone toppling off which did not protect the whole area.

At the time of the tragedy, the care home was without a manager.

The previous manager had been suspended "for matters unrelated to this incident" and Premiere Care, that company that owns Grosvenor Court and another care home, The Willows, in Second Avenue, Cliftonville, was in the process of recruiting a replacement.

After several searches had failed to find Mrs Herring, staff telephoned the on-call deputy manager Lisa Tinkler. The inquest heard that Miss Tinkler had already worked an 11-hour shift. She came to the home in her pyjamas to assist in the search.

In her evidence, Miss Tinkler said she didn't know that the maintenance door used by Mrs Herring existed, although she had worked at the home since July 2018.

Mrs Herring's son Matthew expressed some incredulity at that, but Miss Tinkler insisted she had not known about the door, which, she said, was tucked around the corner at the end of a corridor. She said: "I never had reason to go there."

For KCC, Miss Skinner said social services were concerned that it had taken more than four hours for the home to call the police after Mrs Herring was first noticed to be missing.

She said the home should not have allowed Mrs Herring to go up to her room alone and unsupervised, knowing she was in an agitated state.

She also suggested that Mrs Herring may have been suffering from an untreated urinary tract infection that was the underlying cause of her agitation.

However, when challenged by Susan Jones, a barrister acting for Premiere Care, Miss Skinner was unable to produce any evidence to support that suggestion.

In fact the care records showed Mrs Herring had been given a urine test a few days previously that had proved negative.

The coroner allowed one witness to give evidence by Skype - and when that failed, by mobile phone - because she was at home self -isolating due to coronavirus.

Michelle Jenkins said she had conducted an investigation into Mrs Herring's death for Premiere Care.

She admitted that the the policy then existing about what staff should do if a patient went missing was "unclear." It had now been re-written with a strict time-frame for staff to escalate concerns to management and then to police.

The maintenance door had been re-instated as a proper fire door, with a new exterior escape staircase installed, and was now wired into the alarm system.

Finally, CCTV had now been installed on all floors.

Coroner James Dillon said it was his role to determine facts and not apportion blame.

He could, however, give guidance if he felt there were issues that created a danger of a similar future tragedy occurring.

But, he said, he was satisfied that in this case any issues that might have concerned him had already been addressed.

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