Coroner makes calls for safeguards after Maud Foster death

A CORONER has questioned the working practices of a Boston residential home following the death of a mentally ill woman who went missing and was unchecked by staff.

Frances Ruby Adlard had attempted suicide several times and was receiving psychiatric treatment for depression, yet when she left The Georgians on the morning of August 7 last year and did not return all day, nobody checked where she was.

The 69-year-old was later found dead in the Maud Foster Drain.

At an inquest into her death on Thursday, Paul Cooper, deputy coroner for Boston and South Holland, said he thought more should have been done to keep track of Mrs Adlard’s condition while she was at the home.

Summing up, he said: “There is a policy that the Georgians have, but it doesn’t appear that was followed at all. I would have thought a more robust approach should have been taken at the time.

“I’m not for one minute saying that Mrs Adlard would still be here today but these safeguards need to be in place for all residential care homes of this nature.”

Before moving into The Georgians in August 2010, Mrs Adlard had spent time in Witham Court in Lincoln receiving treatment for mental health problems following a suicide attempt that February, the inquest was told.

She was discharged to The Georgians, where she could receive 24-hour care, with just two sheets of paper detailing her condition and mentioning suicide attempts.

Throughout her time there Mrs Adlard was regularly visited by a community mental health nurse and attended sessions with a psychiatrist, but, despite this, proper mental health risk assessments did not take place.

Patricia Cope, who was matron at the time, told the coroner she had been assured there would not be a problem.

She said: “When she came to me the impression I got was that she was fit enough to live in the community and close observation was not necessary.”

Mrs Adlard’s condition vastly improved while she was at The Georgians, to the extent that she wanted to return to her home in Horncastle. But, just a week before her death she had a disappointing home visit, when she realised she would not be able to manage on her own. During the visit, an occupational therapist asked her if she felt suicidal, to which she replied that she did not at that time, but she could not say how she might feel if she were to live alone again.

Mrs Cope said she did not know about the visit and did not receive a report about the events or the conversation.

Staff at The Georgians did not question her absence from the home as ‘she was allowed to come and go as she pleased’, according to Mrs Cope.

However, even when she had not returned all day, the missing persons’ policy was not put in place, and Mrs Adlard’s body was later found in the drain.

The coroner recorded a verdict of death by drowning.