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Beatrice Baskett appeared on behalf of the family in the inquest touching the death of Joan Chapman. The 5-day Article 2 inquest was heard last week, before HM Area Coroner Ian Singleton, in the presence of a jury.

Joan Chapman sadly suffered from dementia. Since 2019, she had been unable to live independently and had moved to Coombe End Court care home run by the Order of St. John Care Trust in Marlborough, Wiltshire.

On 7 January 2022, Joan walked out of the care home in the middle of the night wearing only her night dress. She was able to leave through a door that was supposed to be locked and alarmed. No one saw her leave or tried to stop her. Tragically, Joan died outside in the garden and was later found there.

The jury concluded that Joan died of hypothermia and found that multiple failings had contributed to Joan’s death, including: not re-activating the external door alarm, not locking the external door and not completing nightly security checks. Additionally there was found to have been a failure to monitor compliance of the nightly security checks and the jury found there was insufficient training of staff, a lack of communication between staff and a poor workplace culture.

The jury found the death was contributed to by neglect.

The family stated in a press statement: “These are difficult findings for us as a family and we will need time to process them. There have since been many changes, and we have been pleased to hear that evidence. We hope it is a testimony to the fact that something like this will never happen again”.

For news coverage of the Inquest see the below:

Beatrice was instructed by Becky Randel of RWK Goodman solicitors.

Beatrice recently recorded a podcast where she considers the coronial concept ‘neglect’: its development, what needs to be proven for a finding of neglect to be returned and examples from her own practice where the issue has been raised. Listen here. She has also recently published an article in the AvMA Lawyers Newsletter where she takes a look at causation in the Coroner’s Court with reference to the inquest touching the death of Mr Steve Dymond and the Jeremy Kyle Show. Read here.