A dementia sufferer was slapped, dragged and locked in her room at a Macclesfield care home, a hearing was told.

Coroner Nicholas Rheinberg said Norma Topping, 68, was ‘abused’ at Hollins Park in Macclesfield at an inquest into her death.

He also found that not enough had been done to protect her from her condition, as she kept walking into things.

Mr Rheinberg found that she had died as a result of bronchial pneumonia, advanced Alzheimer’s and dementia.

However, he also found that a head injury Mrs Topping had suffered a year before her death, which staff and a visiting GP at the home had initially failed to spot, had been a contributory factor.

The hearing was told that her head injury had been caused by an accident. Mr Rheinberg ruled her death was caused was by naturally occurring illnesses and an accidental fall.

At a four-day hearing at Macclesfield Town Hall, Mr Rheinberg said Mrs Topping had been abused on three occasions at the care home.

He added: “The first was towards the middle of June when Norma resisted being changed and was slapped. It was utterly inappropriate.

“In July or August Norma was dragged into her room and later while on the bed was physically pushed back. On August 13, Norma was locked in her room.

“It wouldn’t have been so bad if she was asleep, but we have heard she was awake and distressed. Management was aware of these incidents but failed to act.”

The coroner also concluded that the home was not equipped for dementia patients and that not enough had been done to protect her from her illness. He added: “The management had not taken on board modern safeguarding requirements.

“Mrs Topping’s care plan was not sufficient for her needs. The care was not only lacking, it was abusive. She had dementia and failing eyesight, suffering regular injuries after bumping into walls and doors.”

On the morning of October 3, 2013, staff found Mrs Topping pale and unresponsive in bed after vomiting during the night.

Her condition worsened during the day but they did not take her to hospital, the hearing was told.

The hearing heard that a doctor who examined her said she was dying and she should be left in the home.

But her sister Lilian Selby insisted that she was taken to hospital where a scan revealed she had a fractured skull which a visiting GP and care staff had failed to spot.

Mrs Topping, who was born in Prestbury and lived in Manchester and Handforth, died 12 months later in September 2014 after being moved to Woodlands Care Home in Poynton.

Mr Rheinberg said while the head injury was an accident, it did contribute to her death.

Mr Rheinberg said improvements have since been made at Hollins Park and praised Mrs Topping’s sister for raising concerns.

After the hearing, Sam Harmel, solicitor for Mrs Topping’s family, said: “Lilian is satisfied with the conclusion that there was a failure in her sister’s care but disappointed improvements were only made after her sister’s death.”

Police said an investigation was made but no charges were made ‘on the advice of the Crown Prosecution Service (CPS)’ due to a lack of evidence.

Geoff Fryar, Senior District Crown Prosecutor with Mersey-Cheshire CPS, said: “Cheshire Police submitted two separate files of evidence to the Crown Prosecution Service (CPS) for charging advice against two care workers at the home.

“Upon a full review of the evidence submitted by the police at that time, a decision was taken that it did not meet the evidential test set out in the Code for Crown Prosecutors.

“It was felt that there was insufficient evident to provide a realistic prospect of a conviction for the offences of ill-treatment under the Mental Capacity Act 2005.

“At this moment, the CPS has not been asked to review these cases again.

“If Cheshire Police bring us fresh evidence, we will do so.”

Norma Topping

The care provider in charge of the care home where Norma Topping was abused has admitted standards slipped for a period of time.

A spokesman for Care UK, which runs Hollins Park, said: “Whilst the coroner noted the cause of death as natural causes, we accept that he also heard that for a short period of time in 2013, some of the people working in the home did not follow our procedures, causing standards to slip.

“We reassure residents and relatives that we do not tolerate any instances of poor care and when the matters of 2013 came to light we immediately suspended the two members of staff and reported them to the safeguarding team. The police decided there wasn’t enough evidence to prosecute.

“Following our internal investigations later that year about how the matter was handled, the manager was suspended and resigned and her deputy resigned. We referred them to the Nursing and Midwifery Council. The home is now run by a very experienced manager.”

A spokesman for the Care Quality Commission said: “We were aware of a safeguarding referral made in 2013 and investigation by the police. We last inspected the home in June last year, it was fully compliant.”

Hollins Park Care Home

Care home failed to spot fractured skull which led to patient's death.