The Care Quality Commission (CQC) has launched a criminal investigation into the circumstances surrounding the death of Maureen O'Callaghan, 78, who fell from a window at Berrycroft Manor care home in Romiley, Stockport, on September 29 last year. The coroner ruled that her actions were more likely the result of cognitive impairment and an impaired appreciation of risk, and that risks to her safety were not fully appreciated or acted upon.
Family's trust in the care home
Maureen's family chose Berrycroft Manor after being promised 24-hour care for her at a cost of £1,600 a week, according to her son Nick O'Callaghan. She had been physically active, but dementia was taking its toll. Her granddaughter Olivia said: "At the start she was excited to go in the home. She knew it was what she needed."
Over the course of 2025, Maureen's mental health deteriorated. One month after arriving, she had repeatedly thrown items from her upstairs bedroom window and attempted to climb out of it.
The tragedy and the inquest
On the morning of September 29, a staff member looked out of the curtains and saw something on the floor at around 7.20am, 40 minutes after Maureen was believed to have fallen. Nick received a call at around 7.35am informing him she had had a fall. He said: "I just felt sick. I was in tears. I jumped in the car and drove like a madman. When I arrived, it was a crime scene, there was blood everywhere. I went up the wall."
Detective Sergeant Thomas Hankinson described the window as having a large pane with two letterbox-style openings above it. He felt the opening was sufficient for an adult to pass through. A sensor mat in Maureen's room had been unplugged because it kept going off.
Coroner Jyoti Gill said the risks to Maureen's safety were not fully appreciated or acted upon, contributing to her death. The then-manager, Michael Blissett, said he was not aware of Maureen's attempt to climb out of the window in February 2025, although it was known to mental health services, her GP practice, and care home staff. He did not believe a human being could fit through the window.
Nick told the Manchester Evening News: "She had tried to get out before. She should have been moved to the bottom floor. I'm not a care expert though, it shouldn't be down to me to tell them to move her."
CQC inspection and regulatory action
The coroner did not find neglect but raised concerns about the management of window-related risk and the application of safety guidance. The home has since locked windows, fitted additional restrictors, and reviewed risk assessments and internal inspection regimes.
The CQC returned to the care home a month after Maureen's death and downgraded it to 'requires improvement', finding four breaches in regulation. Concerns included not enough care staff on duty to respond to people's needs in a timely way, particularly at night, issues with medicine administration recording and spacing, risk assessments not always up to date, and ineffective management systems.
Berrycroft Manor had been rated 'good' by the CQC in 2015 and 2018, slipped to 'requires improvement' in 2022, and was restored to 'good' in autumn 2024 after an inspection. Following the inspection after Maureen's death, it was downgraded again.
The inquest heard there was a 'disconnect' between what individual staff members were aware of and what was formally recorded about Maureen. Care plans failed to keep pace with her declining mental health. Mr Blissett resigned in July, and the care home says it is establishing a new leadership team.
Another death at the home
The M.E.N. was also told of another death at Berrycroft Manor weeks earlier. An inquest concluded that Peggy Whyte, 95, had died as a consequence of injuries sustained in an unwitnessed fall in her room, recorded as an accident by coroner Christopher Morris. Police determined there were no suspicious circumstances in either incident. The CQC looked at issues relating to falls at the home following both deaths, but the criminal investigation relates only to Maureen's death.
A spokesperson for Berrycroft Manor said: "Mrs O'Callaghan's death has been felt by everyone at Berrycroft Manor. Our thoughts are with her family, as they have been throughout, and with the family of Mrs Whyte. We accept the coroner's findings in full. Mrs O'Callaghan was in our care, her family trusted us with her, and we are truly sorry."
The spokesperson added: "Immediately after Mrs O'Callaghan's death we fitted additional improved restrictors to every window in the home, not only on upper floors. We have since put in place stronger reporting and documentation processes so that incidents are communicated and recorded properly and improved our risk assessments. Sensor mats remain in use where a resident's care plan calls for one. They are checked at the start of every shift and the check is recorded. We are establishing a new leadership team, including a new registered manager."
A CQC spokesperson said: "The death of Maureen O'Callaghan was a tragedy, and our thoughts remain with her family and loved ones during this difficult time. Following her sad death, we carried out an inspection of Berrycroft Manor from October 20 to 29 last year, to check people were receiving the safe care that they deserve. We rated the home as requires improvement overall. CQC are currently investigating the circumstances around Maureen's death, and are also following the inquest closely."
Following the inquest, Nick O'Callaghan said: "At the end of the day, I put my mum in that care home. It's a decision I will have to live with for the rest of my life."
