Justice for families of nursing home residents in Operation Jasmine inquest

The inquest investigated the deaths of six care home residents - Stanley James, 89, June Hamer, 71, Stanley Bradford, 76, Edith Evans, 85, Evelyn Jones, 87, and William Hickman, 71 – who died  under tragic circumstances in 2005. Hogan Lovells represented the relatives of Stanley Bradford, Edith Evans and Evelyn Jones on a pro bono basis. 

After hearing eight weeks of evidence, on 16 March 2021, Assistant Coroner Geraint Williams gave a summary of a catalogue of failings, accusing managers of “dehumanising” the elderly. The Coroner returned narrative conclusions in relation to all three of Hogan Lovells’ clients, finding that their deaths were a direct result of the extensive pressure ulceration and infections they suffered, which were brought about by a lack of care amounting to neglect.

The Coroner found that the level of care provided was “resolutely below any acceptable standard”. He was highly critical of the care delivered by a number of qualified nurses, the care home’s owners and managers, and the three state agencies that were involved in placing vulnerable elderly adults at the home. The families had been deliberately deceived about the existence of dehydration, malnourishment, pressure ulceration and there had been “a gross betrayal of the trust [they] placed in Brithdir”. 

The Coroner also found that residents at the home were being 'warehoused'. The clinical experts he heard evidence from explained this as “a situation where the residents were simply kept and were being ‘fed and watered’ with the bare minimum being done and then the staff going home”. All of these factors “ contributed significantly to the deaths of Stanley James, Judith Hamer, William Hickman, Stanley Bradford, Edith Evans and Evelyn Jones.”

Commenting at the end of the inquest, Ben Summers, counsel at Hogan Lovells, said: “What happened in the Brithdir nursing home is shocking and tragic. We are anxious to ensure that the outcome of this Inquest is a catalyst for broader scrutiny and significant changes to the standards of care for the elderly in care homes. This is particularly important in the context of the COVID-19 pandemic where the elderly are among the most vulnerable in society.”

Michael Davison, Deputy CEO of Hogan Lovells, who was also involved, added: "Quality legal representation shouldn't be reserved to only the few. It is extremely important to level the playing field for the families, who have waited nearly a decade for an outcome and who would otherwise have to defend their relatives on their own."

In addition to Ben Summers and Michael Davison, the Hogan Lovells team representing the families also included Elise Martin, senior associate, Dervla Simm, senior associate, Josh Redman, associate, Zac Randall, associate, Ed Richards, associate, Scott Macpherson, associate, Georgia Davies, associate, and Alice Jowitt, senior knowledge lawyer, among others. 

Additional background

Brithdir was part of a group of 24 care homes owned by local GP Dr Prana Das and Puretruce Health Care Ltd, a company which he ran together with his CEO Paul Black, whose evidence on his involvement in the running of the home was described by the Coroner as “deceitful”.

Police first launched the Operation Jasmine inquiry in 2005 following the death of an elderly resident at another home in South-East Wales, Mountleigh nursing home.

Over the next seven years, the police investigation was expended to a number of other nursing homes in South-East Wales and some 63 suspicious deaths including the Brithdir Nursing Home where the relatives of our clients were homed. The circumstance of these deaths suggested that it was caused by abuse and neglect resulting from mismanagement of the homes and the substandard level of care.

The Coroner in this inquest criticised the state agencies for missing opportunities to act earlier to stop the abuse which was going on at the home.  Dr Das had been the subject of complaints about his homes since the mid-1990s, when he had been the subject of adverse news reports.  The state agencies were aware of this history and had started protection of vulnerable adult (‘POVA’) processes in relation to other residents at Brithdir in early 2002. 

Although inspections were carried out and improvements notices issued throughout the period 2003 to 2005 and a month-long embargo on the placement of further residents was imposed on Brithdir in November 2004, it was not until 2006 the home was finally closed by the regulator.  The Coroner found that social workers had failed to carry out regular and rigorous assessments of the residents as result of admitted ‘systemic failings’, and that the state agencies should have taken tougher action against Dr Das than they in fact did.

The Coroner also paid tribute to the dignity of the families in their approach to the inquest and their long struggle for justice on behalf their relatives since 2005.  Although Dr Das had been the subject of an extensive police investigation, the Crown Prosecution Service refused to bring any charges. A subsequent prosecution by the Health and Safety Executive was stayed when Dr Das received serious head injuries; he died in 2020 before facing trial.  In the meantime, the Welsh Government ordered a report into the case which was published in 2015 by Dr Margaret Flynn (here). 

Separately, Hogan Lovells is also representing the family of Dorothea Hale in the Grosvenor Nursing Home inquest, which also forms part of Operation Jasmine. That inquest is due to start on 17 May and finish by the end of the month.