Inquest into death of care home resident finds staff did not prioritise resident safety
Margaret Medlicott died on 3 May 2020 after suffering a head injury at Haresbrook Park Care Home in Tenbury Wells
Last updated 1st Aug 2025
An inquest into the death of a 77-year-old woman in a Worcestershire care home has found staff did not prioritise resident safety.
Margaret Dorothy Medlicott, from Southport, died on 3 May 2020 following a fall at Haresbrook Park Care Home in Tenbury Wells.
On 23 April 2020, Margaret, who had advanced dementia, was pushed by another resident and suffered a brain injury.
She was admitted to The County Hospital in Hereford and died 10 days later.
The inquest, which began on 21 July, concluded that neither she nor the fellow resident who caused her death should have been placed at the home, because of restrictions it was under following critical reports from the care watchdog.
Senior Coroner David Reid found that the culture at Haresbrook Park meant that the safety of residents was not prioritised, breaching its duty of care.
The resident who pushed Margaret had previously shown physically challenging behaviour and the coroner said Haresbrook Park did not go through the proper procedures in considering the man's admission.
The coroner said that he had ongoing concerns that further lives could be put at risk and indicated that he would make a prevention of future deaths report around the culture and training at Haresbrook Park.
Following the inquest, Margaret’s daughter, Karen Rosser, said: "Before her dementia worsened, Margaret was known for always being so happy and popular with a wicked sense of humour. She always saw the good in people and they were drawn to her because she had a way of making people feel special.
“She grew up a stone's throw from the River Mersey and went on to see the world, including time spent living in both Canada and the US.
"Our family has been left devastated that Margaret died as she did. Before she was admitted to Haresbrook Park I did all I could to protect her and make sure she was placed in a home suitable for her needs.
“I was repeatedly ignored when I raised concerns that the extent of my mother’s complex needs and challenging behaviour was not appreciated or being taken into account by those who should have looked after her. It was against this backdrop that she was admitted to Haresbrook Park when she should not have been, and where she was not kept safe.
“My firm view is that systemic issues led to my mother and the man who pushed her to be placed in the home, and that Haresbrook Park appeared to be motivated by its own financial interest to accept them both when they should not have.
"The devastation my mother's death has had on our family will remain with us all for the rest of our lives.
"We sincerely hope that what happened to Margaret never happens again”.
Mrs Medlicott’s inquest was delayed while investigations were carried out by the CQC and West Mercia Police and no criminal charges have been brought.
A spokesperson for Haresbrook Park care home said: “First and foremost, our heartfelt sympathies are with the family of Mrs Medlicott. We are truly sorry for their loss.
"It was important to all of us that we learned from this incident, and we have taken this exceptionally seriously. In the five years since Mrs Medlicott’s death, we have made a number of important changes at our home.
"With a permanent and experienced Home Manager in place, we have transformed our approach to assessments, care planning, and colleague training – including a new dementia programme. We continue to work closely with the CQC and our Local Authority partners to embed these changes.
"These improvements – coupled with no longer being under the extreme and unique pressures the COVID-19 pandemic placed on care homes at the time – mean that our home is a very different place today. Our focus remains on providing safe, compassionate care to all those who make their home with us.”
A statement from Worcestershire County Council said: “On behalf of Worcestershire County Council, our thoughts and condolences remain with Mrs Medlicott’s family and all those impacted.
"We carried out a Safeguarding Adults Review, which was published by the Safeguarding Adults Board in 2023, and took immediate action to strengthen our practice in several key areas.
"We will continue to work with the care provider to ensure the quality of care is of the standard we would expect for our residents.
"Following the inquest, we will continue to work with our colleagues on the Worcestershire’s Safeguarding Adults Board as they implement their post review action plan to further improve how agencies work together.”