Death of care home resident after third attack by fellow dementia patient was 'avoidable', says coroner

"Coroner Lydia Brown ruled the assaults contributed to Mr Edgar's head injury, along with at least four unwitnessed falls he had at the home, run by Greensleeves Care, and age-related decline. Ms Brown said: [Mr Sweetmore was] a wonderful, gentle, sociable man, with an interesting career in the arts. He lived a long and much-loved life. The end of his life was sadly marred by both natural disease processes, but also violence in the very place where he should have been safe."

"Mr Edgar moved to Viera Gray in March 2020, where his wife was staying as she was in the later stages of dementia. He was described as a very loving husband but protective of her, which led to difficulties with carers due to his own dementia. The inquest at West London Coroner's Court heard Mr Edgar showed escalating violence and aggression towards staff across six incidents in April and May 2020, which were not reported to Richmond Council's Adult Social Services."

An 86-year-old resident, Neil Sweetmore, suffered a fatal head injury and later died of pneumonia on September 11, 2020, following an assault on August 25 at Viera Gray House in Barnes. The assailant, John Edgar, had dementia and showed prior escalating violence and aggression during earlier incidents in April and May 2020 that went unreported to Richmond Council's Adult Social Services. The coroner attributed the head injury to assaults and multiple unwitnessed falls, compounded by age-related decline. The coroner found the unit lacked sufficient staff and that inadequate communication between the home and external agencies prevented appropriate safeguarding.

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