Rosemary Sherrington fell over at Cavell Court, in Cringleford, but paramedics were not called for around six hours.
The former science teacher and Ofsted inspector's condition continued to deteriorate and she died in hospital a week later.
Karen Curle, the care home manager, told Norfolk Coroner’s Court that staff would have called 999 sooner "if communication had been clearer".
The inquest into Mrs Sherrington's death heard there was a discrepancy between staff over whether she had banged her head in the fall - which had an impact on how she was monitored.
While the carer on duty said he saw her hit her head and had told a senior colleague, the team leader and another colleague disputed this.
Samantha Goward, the area coroner, said: “Evidence stated that the care worker who saw her fall had advised that she did hit her head as she fell on the floor.
“However, there is a discrepancy in the information given to the care home and to my staff.
“The career [on duty] said he saw her hit her head and had told a senior colleague – but the team leader and another colleague denied this.
“The team leader then completed the incident form and recorded no head injury.”
The hearing was told Mrs Sherrington had been diagnosed with Alzheimer's disease in 2014.
Her family had cared for her at home, but she moved into Cavell Court after two falls.
The court heard that she fell at the home on January 10 last year.
She was checked for injuries and was put on hourly observations, which were carried out until 7pm.
She was then not checked until 10pm, when she was found unresponsive in her room.
Mrs Goward continued: “The explanation for this was that staff were busy helping other residents to bed.
“There is therefore a three-hour gap with no recorded observations, so we do not know when Rosemary began to deteriorate.”
Mrs Goward added: “I find that further action should have been taken when Rosemary was seen to hit her head on the floor.
“Evidence from the care home manager, Karen Curle, accepted that if communication between the team had been clearer, 999 would and should have been called sooner.
“It is not possible to know what the wait for the ambulance would have been at that time. However, while awaiting an ambulance Rosemary would have been closely monitored.
“I accept that the carers are not nurses but they knew Rosemary well and therefore they would have spotted any deterioration from her normal circumstances.”
When paramedics arrived they advised she had a hematoma on the back of her head.
She was taken to the Norfolk and Norwich Hospital where a CT scan revealed a “signification and life-threatening brain injury”.
Despite this, it was confirmed that an earlier scan would not have changed the outcome.
Mrs Sherrington continued to deteriorate and died in hospital on January 17.
The medical cause of death was given as a subdural hematoma following a fall.
The court heard how staff at the care home had undergone further and robust training following the incident
Miss Curle apologised to the family and reaffirmed the care home’s commitment to its residents.
'EDUCATION WAS HER LIFE'
Rosemary Sherrington (nee Barlow) was born on February 11, 1939, in Alton, Hampshire, and was the wife of Barrie Sherrington, a retired computer engineer.
She completed her teaching training at Keswick Hall College of Education, near Norwich, and taught science and biology.
She went on to become a science advisor for Norfolk Education and Learning and lectured at universities, before becoming an Ofsted inspector and education consultant.
A breast cancer survivor, she also wrote education textbooks but had been working on a book about her grandfather’s experience of the First World War before her dementia diagnosis.
Her family said: “She knew a lot of people and she was universally liked. She was really lovely.
“A lifelong learner, she really encouraged us all to learn and never shied away from difficult conversations.
“Education was her life.”
login
who are we?
contact us
qosheapp
Toi Staff
Gideon Levy
Belen Fernandez
Andrew Mitrovica
Mort Laitner
Ali Fathollah-Nejad
Rami G Khouri
Nikkei Editorial
visit website
