Worcestershire care home staff did not prioritise resident safety before death of grandmother Margaret Medlicott, coroner concludes

Senior Coroner David Reid found that the culture at Haresbrook Park care home in Tenbury Wells, Worcestershire meant that the safety of residents was not prioritised, breaching its duty of care.

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.

Margaret, 77, a grandmother of three, died at The County Hospital, Hereford on Sunday 3 May 2020, 10 days after being deliberately pushed over by another resident and sustaining a serious head injury at the care home. Both Mrs Medlicott and the resident who pushed her had advanced dementia.

Margaret was born in Southport, Merseyside during the Second World War but grew up in Bootle, before later moving to Hereford.

Throughout Mrs Medlicott’s life she and her husband, Edward had also lived in Toronto, Vancouver and Montreal in Canada, and in the US in Seattle and St Louis. 

The inquest was held at Worcestershire Coroner’s Court, Stourport-on-Severn between Monday 21 July 2025 and Wednesday 30 July 2025. It concluded on Friday 1 August 2025.

The coroner was told that both residents were admitted to Haresbrook Park in early 2020 at the start of the COVID 19 pandemic. 

The care home was under admission restrictions, agreed with Worcestershire County Council, following critical Care Quality Commission (CQC) reports in the previous year and issues with the home identified by the council.

Margaret’s daughter, Karen Rosser had strongly objected to her being placed at Haresbrook Park because of her concerns it would not be safe for her mother’s complex needs.

In his narrative conclusion, the coroner found that neither Mrs Medlicott, nor the resident who pushed her, should have been placed at Haresbrook Park because of the restrictions.

He said that Margaret should not have been admitted because of a ban on accepting residents through a pathway where patients are not fully assessed before leaving hospital known as D2A / Discharge to Assess, and a ban on admitting residents with challenging physical behaviour.

Herefordshire County Council placed Margaret at the care home, but the coroner said Worcestershire County Council failed to tell the local authority about the restrictions.

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 inquest heard that the man had been admitted a few weeks before Margeret, after his family had become unable to cope with his unpredictable and increasing violence caused by his dementia. This had included stomping on a family member’s head, punching them, and pushing them into furniture. 

The owner of the care home, its nominated individual, and other Haresbrook Park care staff gave evidence, as well as witnesses from Worcestershire County Council. 

The nominated individual, an external consultant, said that she had been brought into the home while it was in crisis because of its history of poor regulatory compliance. 

The owner of Haresbrook Park explained that the restrictions had left the care home more than half empty and financially underperforming significantly and that it needed to new admissions for the business to survive. 

The coroner found that the owner had taken the decision to admit the man who pushed Margaret, despite having neither the qualifications nor clinical experience to do so. Had someone with the proper qualifications assessed his admission, the coroner said, they would not have agreed to admit him.

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.

Margaret’s daughter, Karen Rosser is represented by Leigh Day partner, Merry Varney and solicitor Caleb Bawdon, with Olivia Fletcher.

Following the inquest, 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”. 

Leigh Day solicitor Caleb Bawdon said:

“When our loved ones move into care, we place immense trust in the professionals charged with their protection, and expect the systems designed for their safety to be rigorously upheld - Margaret and her family were desperately let down.

“In evidence we heard that the resident who pushed Margaret had become increasingly violent, and this was why he was placed into care.

“The coroner was told that Worcestershire County Council was aware of this man’s aggression and still helped place him at Haresbrook Park. This is the same local authority which had agreed a restriction with the care home saying it must not admit residents with physically challenging behaviour.

“Having waited five years for the inquest into her death, Margaret’s family welcome the coroner’s conclusion and the recognition that a series of failures led to her death. They have always believed Margaret’s death was avoidable, and that both she and the resident who pushed her deserved far better.”

Angela Patrick of Doughty Street Chambers is instructed as counsel for Mrs Medlicott’s family.