Less than two weeks ago local media were full of reports on the Coroner’s Inquest into events at Holmesley Care Home (Sidmouth), where Covid took the lives of seven residents in March and April 2021.

The Coroner concluded that events at the home contributed more than minimally to the deaths of the residents.

During the Inquest family members were unified in questioning whether justice had been served by the actions taken by the CPS, Police, CQC and other agencies – all in place to protect vulnerable, elderly residents.

The scale, the litany of events that pointed at poor management at Holmesley only became evident when families received witness papers just ahead of the Inquest, three years after the events back in March/April 2021.

A CQC inspection in February 2021 reported that the service was not safe and not well-led and that people were not protected from avoidable harm or risk of harm.

Despite this, prosecutions against key individuals had been dropped by the CQC, CPS and consequently by the police.

The Coroner reported that clear processes and unambiguous procedures were in place at the home but that evidence illustrated that these measures were not followed consistently by all staff members.

Decisions on possible disciplinary action by the Nursing and Midwifery Council (NMC) are eagerly awaited on the behaviours of two members of former staff at the home.

A barrister friend, who has extensive knowledge of the operation of the care sector, was appalled by the manner in which the Holmesley affair had "fallen through so many cracks in the law" that nobody was prosecuted and that the door remains open for similar transgressions by care home staff.

Families are thankful to a whistleblower at Holmesley who had shed light on how positive LFT results were ignored and binned, how staff who had tested positive for Covid were rostered to work by a manager and how an individual who believed in Covid conspiracy theories consistently ignored PPE directives at the home was neither suspended nor dismissed.

Family and vulnerable residents had expectations that care home managers would discharge their duty of care to the elderly with a passion.

Residents were seriously let down by the few.

Elderly residents and their families, seemingly, had very little voice back in Spring 2021 during the Covid period.

With the care home in effective lockdown family members were unable to witness and challenge the poor implementation of Covid prevention measures.

Individuals with complaints about care home management are unable to approach the CQC or agencies such as the HSE.

Some good will come out of the Inquest.

Family members are putting pressure to see changes in the Law that will prevent similar transgressions by care home staff that can have disastrous results.

Our local MPs have a role to play in asking questions in The House in order that gaps in the Law are closed and that the CPS and Police have effective powers of prosecution.

The National Covid Inquiry could consider reviewing the litany of mismanagement at Holmesley with a view to closing legal loopholes.

The Coroner proposed improvements to how residents and their families can meet regularly with managers to air issues and complaints.

Care Home contracts should now have built-in rights and routes to communicate concerns and complaints or safeguarding issues and incorporate rights for whistleblowers.

Other families will be heartened to learn that access is available to individual family members or residents to an Ombudsman service to air concerns or complaints.

Contact should be made with the Local Government and Social Care Ombudsman.

As a postscript Holmesley is now under new ownership with a fresh management team and has incorporated the elements for improvements highlighted by the Coroner and has achieved good CQC reports and has a good reputation as a care home.

Mick Koch
Ottery St Mary