Patricia Barnett, 84, died just over a fortnight later, on 13 March, after suffering a fatal head injury in an unwitnessed fall while left unsupervised in Peterlee Care Home on the evening of 26 February 2026.
Following an inquest in May, assistant coroner for County Durham and Darlington Rebecca Sutton issued a formal prevention of future deaths notice, requiring the care home operator to explain how it will mitigate the risk of a similar incident.
What the coroner found
The coroner found that Mrs Barnett "died due to a head injury sustained in an unwitnessed fall at the Peterlee Care Home". She said: "Mrs Barnett suffered from Alzheimer's Dementia and was unable to mobilise independently. During the late evening of 26 February 2026 Mrs Barnett was in the lounge area of the care home. She had been given medication to 'manage her behaviour' and was reported to be sleepy. She was known to be at high risk of falls due to attempting to mobilise without assistance."
Ms Sutton added: "There had been members of staff present in the lounge area in order to monitor the residents (including Mrs Barnett), but the staff had left the area to assist another resident to go back to their room. While Mrs Barnett was left unsupervised in the lounge area, she had an unwitnessed fall. As a result of that fall she suffered a serious injury to her head, which resulted in her death."
She said: "I am concerned that Mrs Barnett was left unsupervised in the lounge area. I am concerned that there is a risk that future deaths could occur if residents who are suffering from reduced mobility and cognitive impairment and who are at high risk of falls are left unsupervised in the lounge area of the care home."
Care home response
In its response to the notice, the home's management said measures "were in place at the time" of the fall to help prevent it, including staff allocated to oversee the lounge area, chair sensors for those at risk of falls, and applications for one-to-one support. It said oversight of the lounge area was "more challenging overnight" due to lower staffing levels, and that requests for funding towards one-to-one support were often declined by the local authority.
Bosses added: "What we will implement going forward is that residents who are at risk of falls will be the priority residents to support to bed, this will reduce the risk of highfalls risk residents being unobserved in communal areas. This is dependent on the choice of the resident. We will continue to use assistive technology such sensor mats and chair sensors to alert staff if a resident is standing. We will continue to request 1-1 funding to support those at risk of falls, but as stated these are routinely declined by the local authority."
A spokesperson for the home said: "Our thoughts and condolences are with Patricia's friends and family. She had been a resident at our home for almost a year and will be missed. This was a very sad accident, and we have taken action to put in place further safeguards to help prevent this happening again. The coroner has been made aware of our actions."
