Warnings about a care-home resident who had previously become violent were not resolved before a 95-year-old man was fatally injured in an unprovoked attack due to an island-wide bed shortage, it has emerged.

The revelation came during an inquest into the death of Douglas Arthur Davies, which also surfaced concerns about the care he later received in hospital, where a postmortem found he had not been given adequate nutrition or hydration following hip surgery.

Mr Davies – known as Doug – was a resident at Lakeside Manor Care Home in St Saviour, where staff described him as quiet but “popular”.

The inquest heard that another resident at the home had previously displayed violent behaviour towards both staff and patients in April and May 2023.

“Unbroken link” between push and death

Registered manager Rosie Goulding said those incidents were believed to be linked to physical illness, such as infection, but concerns about the safety of other residents had led the care home to give notice for the man to leave.

On 29 August 2023, CCTV showed Mr Davies walking past the resident in the care-home lobby when he was pushed with both hands “without apparent provocation”, causing him to fall and fracture the neck of his femur.

The 95-year-old was taken to the Emergency Department and underwent hip replacement surgery, but his condition deteriorated in the days afterwards.

Mr Davies died on the morning of 4 September 2023.

A postmortem later found that Mr Davies had not received enough nutrition or hydration during his recovery in hospital.

Dr Simon Chapman, chief of surgical services, told the inquest that while this would not have caused Mr Davies’s death, it would have affected his recovery.

The postmortem concluded there was an “unbroken link” between the push and Mr Davies’s death, stating that the complications “would not have arisen” had he not fallen.

No beds available for violent resident

The inquest also heard that the care home thought mental health services were looking for a better placement. With no beds available initially, they believed a search was ongoing – but due to a misunderstanding, the older adult mental health team thought that the request had been withdrawn.

Deputy Viscount Advocate Matt Berry, sitting as coroner, said the process “could be looked at” because of the risk of misunderstanding.

Following the incident, the resident who pushed Mr Davies was assessed under the Mental Health Law and moved to a specialised ward.

Criminal charges were not pursued because of the man’s cognitive impairment, described during the hearing as delirium.

Advocate Berry concluded that Mr Davies died from multiple organ failure following hip replacement surgery necessitated by the fracture, with dementia and old age contributing factors.

Changes made

In a statement read to the court, Mr Davies’s family said they were “extremely proud” of him and “grateful for everything he did for them”.

Simon West, Medical Director for Health and Care Jersey, offered his “deepest sympathies” to the family and said a “full and detailed review” had been carried out following the death.

“Several measures have been implemented,” he said.

“We also continue to strengthen our approach to supporting patients’ hydration and nutritional needs as a fundamental part of safe and compassionate care across all our services.”

The Jersey Care Commission said it had initiated its regulatory processes following notification of the incident and worked with relevant stakeholders to support a “full and transparent understanding of the circumstances”.