The brother of a woman who died following an incident at a Grimsby care scheme when she should have been watched around the clock has told how "lessons must be learned".
Georgina Hallam, 47, died in August 2022 at Bradley Complex Care Apartments in Grimsby, a specialist facility which supports adults with learning disabilities, having been placed there eight months earlier by Nottinghamshire County Council Adult Social Care. Georgina was undergoing support and treatment following mental health struggles, including numerous attempts on her own life.
Both Nottinghamshire County Council and Elysium Healthcare Ltd which runs the care apartments have extended their sympathies to Georgina's family and the latter said changes had already been made. Nottinghamshire County Council said it was reviewing the findings to ensure lessons are learned and improvements made.
Despite being born with cerebral palsy and having a speech impediment and partial deafness, Georgina had built an independent life after losing both of her parents just three years apart. Working six days a week in a charity shop, she lived in her own home with the support from her brother Anthony.
However, that routine was thrown into turmoil during the Covid-19 pandemic. An inquest into her death - held over a week by Greater Lincolnshire coroner Jayne Wilkes - revealed the devastating chain of events leading to her death.
GP records showed that, without being able to spend time with friends and work colleagues, the lockdowns took a heavy toll on her mental health and, between June 2020 and December 2020, Georgina was admitted to emergency departments 30 times, for overdoses, falls, headaches and seizures. Placed in the Bradley Complex Care Apartments, Georgina's care plan stated she must always be under one-to-one supervision - at all times - for her own safety, and therefore always be in sight of a member of staff, even when she went to the bathroom or toilet.
On the fateful occasion, however, the apartments were short-staffed and had only one female staff member working - and Georgina was allowed to go into a toilet alone by a male agency worker, who was observing her for the first time. The agency worker had not seen Georgina's care plan, and although he knew she was on one-to-one observations, he did not know why and was not aware of the seriousness of her self-harm risk, so made the decision to allow her some 'privacy and dignity'.
The worker was unaware that Georgina had gone into the toilet with the main aim of swallowing an item. A female colleague asked where Georgina was, and when told she was in the toilet alone immediately went to check on her.
Georgina was discovered lying on the floor on her side, clutching her hand to her stomach. She was placed in the recovery position while they awaited emergency services. However, paramedics said it took four or five minutes before anyone let them into the building when they arrived, with Georgina in cardiac arrest, having no pulse and not breathing. After carrying out CPR, her pulse returned and she was taken to the Diana Princess Wales Hospital in Grimsby.
However, she died three days later, on August 8 2022. As previously reported, the case was referred to the Care Quality Commission (CQC) to conduct its own investigations. The commission carried out an inspection at Bradley Complex Care Apartments following Georgina's death.
Last week, the inquest into her death heard there had been admissions of failures from Nottinghamshire County Council with regards to assessments of Georgina's mental capacity, leading to agencies involved in her care being confused about her status.
The coroner also noted failings by Elysium Healthcare Ltd, which included not giving specific reminders to staff about the need for 24-hour observations, especially those who did not care for her regularly, and of the need for additional vigilance.
Heartbreakingly, the inquest heard expert evidence that Georgina's acts of self-harm were likely to be her seeking a care response - and that she would have believed she would always be saved. The hearing was told she would not emotionally grasp and understand the potentially fatal consequences of her actions.
Greater Lincolnshire coroner Ms Wilkes said there had been "insufficient precautions in place to address the known risks and triggers to Georgina" on the night she was left alone in the toilet.
Recording death by misadventure, the coroner concluded: "On the balance of probabilities, she died from the unintended consequences of her self-inflicted act. At the time this occurred there were insufficient precautions in place to address the known risks of this occurring."
Following the inquest, her brother Anthony has told how organisations must learn from Georgina's death. He also told of his pride for the life she had made for herself, overcoming the deaths of both their parents within three years.
He said: "From birth Georgina had to undergo many operations and throughout life had many difficulties, which she faced with courage. She got a volunteer job, which later turned into a paid job, at a charity shop. This gave her the feeling of having a normal life and this was a phrase she used constantly following our parents' deaths.
"Having provided her with constant assistance throughout this period she yet again managed to overcome the circumstances and dealt with the day to day running of a household. She was proud of this. All she wanted was that normal life, and hopefully she enjoyed the time she had. Georgina's memory lives in my heart and the others that had the privilege of knowing her. I will forever miss her."
Anthony was supported through the inquest in Lincoln by Iftikhar Manzoor and Soraya Mehdizadeh, of Hudgell Solicitors. Mr Manzoor said the inquest had identified a string of "inexcusable" failures.
He added: "Georgina was completely let down. She was in a specialist facility because she was a threat to her own safety. It was meant to be a place where she would be kept safe by a specialist team."
"There was a very clear care plan in place which said she had to be observed at all times, including visits to the toilet. This had even been explained to Georgina herself as she had made previous attempts on her life, and had also previously swallowed a similar item in her room.
"As this could upset Georgina, as she felt like staff were always watching her, they were told to remind her that it was being done to keep her safe. A life was lost here because the most basic of instructions were not followed.
"There was no effective system in place to ensure an adequate number of female workers on site during each shift, and that agency staff, or staff covering from other roles, were properly briefed in regard to patient care plans particularly for patients with significant suicidal intent for whom critical risk mitigation measures had been put in place. These were inexcusable failings."
A spokesman for Elysium Healthcare said: "We continue to send our deepest condolences to Georgina's family and friends following her tragic death in 2022. A full and thorough investigation was undertaken at the time of this incident and as a consequence improvements were made regarding observation policies and staff training.
"At the conclusion of the inquest the coroner was satisfied that Bradley Apartments is a safe place for some of the most vulnerable members of our community to live. The service was recently inspected by the CQC and rated as 'Good'."
Nottinghamshire County Council's Interim Executive Director of Adult Social Care, Guy VanDichele, said: "We extend our deepest sympathies to Georgina Hallam's family and all those affected by her tragic death. The Coroner's formal conclusion was that Georgina died as a result of misadventure following a self-inflicted act.
"The inquest highlighted the complexity of her needs and the challenging circumstances surrounding her care. We are reviewing the Coroner's findings carefully to ensure that lessons are learned and improvements are made across relevant processes. Given the sensitive nature of this case, it would not be appropriate to comment further at this time."