Eileen Dean, 93, was killed by a resident more than 20 years younger who had a history of violence.
Image source, FieldsideNo formal risk assessment was done on a man who beat a fellow care home resident to death, a review has found.
Alexander Rawson attacked 93-year-old Eileen Dean with a metal walking stick at a care home in south-east London.
Mrs Dean suffered catastrophic injuries to her head and body and died later in hospital.
A review found Fieldside Care Home in Catford did not provide the specialist mental health services that Rawson – who had a history of violence – needed.
Last year, Rawson was given an indefinite hospital order by a judge at the Old Bailey after it was decided he was mentally unfit to stand trial.
Rawson, who had a history of mental health problems caused by alcoholism, was 62 when he was placed in the home a few days before Christmas 2020.
He was put in the room next to Mrs Dean and, in the first week of 2021, he went into her room at night and attacked her.
In a review published on Friday, the Lewisham Safeguarding Adults Board said Rawson had been moved into the home after being an inpatient at a psychiatric unit run by the South London and Maudsley NHS Foundation Trust.
The care home was the only place that agreed to take him after his discharge from hospital.
Image source, Metropolitan Police
The report described how Rawson was moved between four hospital wards and a care home in three locations and between two NHS trusts with information not gathered, recorded correctly or passed on.
In the months before he was moved into the care home, Rawson was involved in at least 34 recorded incidents of violence or threats to patients and health staff, including a threat to kill.
He had threatened to use a bread knife, scissors and dinner trays as weapons, had thrown jugs of water and cups and smashed equipment including computers, a radio and a crash trolley.
Before he was placed in the home, no attempts were made to find out whether Rawson had come into contact with the criminal justice system over his behaviour, the report found.
It states that the care home had asked about the risks Rawson posed before they took him and had been reassured by a social worker and medical staff.
The review also found that when the care home agreed to take Rawson, it had not told the watchdog, the Care Quality Commission (CQC), that it was housing people under the age of 65 with certain mental health needs.
A CQC spokesperson said: “The circumstances of Eileen Dean’s death are appalling and our thoughts are with everyone affected.
“Health and social care providers must ensure they adequately assess the needs of people receiving their services, and collaborate to ensure appropriate placements are made.
“This includes sharing all relevant information when a transfer is being considered, so a person’s new service can assess whether it can meet their needs while ensuring the safety of other people using the service.”
Mrs Dean’s daughter Georgina Hampshaw said in a statement: “It is with great sadness and regret that the published report confirms our worst fears of the many failings by the various agencies and trusts charged with managing the care and placement of the person responsible for the death of my mother Eileen Dean.
“The decision to place this person at the care home where my mother resided could not have been more flawed and resulted directly in the horrific murder of my gentle mother.
“Numerous opportunities were missed by so many agencies that may have prevented the horrific incident.
“I sincerely hope that the recommendations detailed within the report are adopted expeditiously and in full.
“No other family should have to suffer the loss of a loved one in such tragic circumstances.”
Image source, Family photo
Nathalie Zacharias, director of therapies at South London and Maudsley NHS Foundation Trust, said: “We welcome the report’s findings and recommendations and have conducted our own full investigation which identified where we can make improvements to the care we provide.
“This includes putting robust checks in place to ensure all known risks, including those which take place off our premises, are fully recorded and documented and ensuring people in our communities continue to receive the care and treatment most suitable for their needs.”