INFORMATION on an elderly man's dementia was intentionally withheld by the Isle of Wight Council to ensure he was given a place in a care home.

That was the conclusion of the Isle of Wight coroner, Caroline Sumeray, who described the circumstances surrounding the death of Frederick 'Joe' Sheath at Fallowfields Care Home in Ryde as a "recipe for disaster".

At the time of his death in 2015, the County Press ran a blistering front-page story, quoting Mr Sheath's daughter as saying the council had blood on its hands.

A five-day inquest last week heard Mr Sheath had only recently moved from the Holmdale House care home in Havenstreet, after serious concerns about that home were raised by watchdog, the Care Quality Commission.

Mr Sheath suffered with severe dementia and as a result was prone to wandering in the night — a fact known to staff at Holmdale but not at Fallowfields.

His wandering had been a feature in documents made during his stay at Holmdale but during his move to Fallowfields in 2015, thee were not shared with staff at the new home.

The inquest heard how on the morning of March 19, 2015, staff at Fallowfields discovered Mr Sheath lying unconscious at the foot of a set of steps leading from a fire escape at the rear of the property.

A nurse working the night shift prior to Mr Sheath's fall helped take him to the toilet, but only two people were on shift that night and she was called away to assist with another job.

Mrs Sumeray said: "After that she made her way to the dining room to clear away the dining room, forgetting about Mr Sheath. A serious lapse in judgement from a carer of 22 years.

"At around 8am, staff discovered Mr Sheath, tangled in his zimmer frame.

"He had wandered out of the toilet and into another patient's room, from there he saw the fire escape and walked through it."

In 2014, the CQC deemed Holmdale House as inadequate, prompting the council to pull all future placements with the home.

Mrs Sumeray said: "Around this time, the owner of Holmdale had seen an attempt to sell the home fall through and as a result the council was left with seven days to move all patients under its care.

"The report also found documents regarding patient care plans were not regularly updated.

"When representatives of the council visited Holmdale after it was closed, they found huge amounts of documents pertaining to patients that had been left unsecured and out in the open.

"Had Carol Montague, the owner of Fallowfields, been made aware some documents were inadequate, she may have made further enquiries.

"We have seen that a 2014 document entitled 'all about me' detailed Mr Sheath's propensity to wander. The council had this document and it wasn't disclosed to anyone.

"This was a recipe for disaster. I am confident he would not have been offered a place at Fallowfields had the nature of his issues been properly disclosed.

"I conclude Mr Sheath's behaviour was intentionally left out of details given to Fallowfields by the council on the assumption that they would accept him.

"This rush was relative to the pressure on social services to get him into a home."

The court heard how the Isle of Wight Council has now updated its contract with care homes, compelling them to provide six months notice before they are able to close a care home.

Mrs Sumeray concluded Frederick Sheath died as the result of an accident, stemming from a traumatic head injury and dementia.

Update 4.05pm: The Isle of Wight Council's director of adult social care and housing needs, Dr Carol Tozer, said:

“I would wish to reiterate the council’s deepest condolences to Mr Sheath’s family, with whom we have previously met and apologised for omissions in making arrangements for his care.

"Understandably, they have been desperate to get to the heart of what happened to their beloved father. They have had to wait five long years for this to come to a conclusion and endure gruelling, lengthy testimony in the coroner's court detailing the circumstances of how he died and was found.

“The coroner concluded that his death was as a result of an accident. There were issues including omissions in our adult social care practice which arose out of the urgency to find an alternative care home for Mr Sheath. This included not providing Fallowfields residential care home with a written copy of the social care assessment of Mr Sheath’s needs conducted in February 2015.”

Dr Tozer, who joined the council almost two years after Mr Sheath’s death, gave evidence that many changes had been made in adult social care since 2015 to reduce the risk of such a tragedy happening again.

These included the creation of the department’s Single Point of Commissioning (SPOC) team — so care homes have a single point of reference to inform their decision on whether or not they can safely meet someone’s needs.

There are also updated policies and procedures around consent and information sharing — giving explicit instruction that both the SPOC team and the social care worker must provide a copy of the full care plan to care homes and other providers.

Dr Tozer also advised that a council initiative to raise standards in the care sector by giving free training to all registered managers in care settings had been highly successful.

There were now no Island residential or nursing homes rated as ‘inadequate’ and more than 80 per cent of all registered care provision is now rated as ‘good’ or ‘outstanding’ by the Care Quality Commission.

Dr Tozer added: “We have introduced new ways of working affecting both commissioning and social work practice designed to ensure that if and when frail elderly people must be moved from one care home to another, it is done in a planned and properly co-ordinated fashion, using a very clear framework of who is responsible for doing what, by when and how."

During the inquest, the coroner praised Dr Tozer’s passion, drive and determination to make things better for the Isle of Wight.