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North Court Care Home, in Northgate Street, Bury St Edmunds, manager apologises to family of Sonia Sore who died after fall




A care home manager apologised to the family of a much-loved former pub landlady who died after falling out of her bed.

An inquest heard Sonia Sore, 84, died on November 8, 2023 after suffering a head injury during the fall at North Court Care Home, in Bury St Edmunds, on October 20.

Yesterday, Suffolk Coroner’s Court heard this was the great-grandmother’s second fall in the space of a week – the first occurring on October 14 after which her care plan was updated to say both rails on her bed should be raised.

Sonia Sore with her children, Joy Bentley and Andrew Gibson, celebrating her 80th birthday. Picture: Submitted
Sonia Sore with her children, Joy Bentley and Andrew Gibson, celebrating her 80th birthday. Picture: Submitted

Nicolae Nicolescu, North Court’s home manager, conceded at the hearing this was not actioned, which resulted in the second fall.

Addressing Mrs Sore’s family, he said: “I offer my deepest apologies. I feel sorry for what happened.

“I could have done better and, for the future, probably I will think twice.”

Sonia Sore with four of her great granddaughters. Picture: Submitted
Sonia Sore with four of her great granddaughters. Picture: Submitted

Her cause of death was a large left acute subdural haemotoma and coroner Darren Stewart will issue a prevention of future deaths report to the home’s owner Maven about a perceived lack of consideration given to the importance of risk assessments.

Mrs Sore ran The Volunteer Arms in Mildenhall with her husband Donald for 16 years from 1976, was the Mayoress of Greene King Licence Society and was a carer at a residential home in Newmarket.

She moved into Northcourt, in Northgate Street, in 2017 and broke her hip in a fall in 2020.

Sonia Sore with daughter Joy Bentley, her granddaughter and two of her great granddaughters at North Court Care Home. Picture: Submitted
Sonia Sore with daughter Joy Bentley, her granddaughter and two of her great granddaughters at North Court Care Home. Picture: Submitted

Deemed by the care home to be a medium falls risk, it was judged her bed rails should be raised to keep her safe.

However, Mrs Sore objected to this as she wanted to maintain some independence, so only one rail, on her left, was raised at night.

Paralysed on her right hand side following a stroke in 2014, she had to reach across her body from the left to access a nightstand.

Sonia Sore with John Sore. Picture: Submitted
Sonia Sore with John Sore. Picture: Submitted

Her family was not informed of the first fall until three days later on October 17.

After this, the home decided both rails needed to be raised when she was in bed, but this did not happen.

During the hearing, Mrs Sore’s daughter Joy Bentley told North Court’s manager she would have been able to persuade her mother to sleep with both bed rails up but highlighted the lack of communication from the home’s management with her family.

Sonia Sore with all 3 of her grandchildren and two great grandaughters. Picture: Submitted
Sonia Sore with all 3 of her grandchildren and two great grandaughters. Picture: Submitted

The inquest heard from Ian Buckland, Four Seasons healthcare regional manager, and Iqbal Sidhu, care quality lead for Maven Healthcare, on action taken in the wake of Mrs Sore’s death.

During her time at the home, North Court was managed by Four Seasons, but on January 29, 2024, it was purchased by Maven.

Ms Sidhu said, at the time of Mrs Sore’s falls, the home was using 50 per cent agency staff, but the new operators had reduced this number to zero.

Recording a verdict of death by accidental causes in a narrative conclusion, Mr Stewart said no attempts were made by staff to engage with Mrs Sore over the risk she was taking by refusing to have her right hand side bed rail raised.

He said the issue was not raised with Mrs Sore’s family, who may have helped persuade her of the risk.

There was no evidence of staff attempting to find alternative solutions having taken the decision not to raise the bed rail, he said.

After the hearing, Mrs Bentley told SuffolkNews her mum was a caring, family woman who loved being a mum and was well loved at the care home.

“As I reflect upon it, it was the outcome that she deserved, that we deserved,” she said. “We have now got closure.

“I hope they (the home) learn for her friends still living there and it doesn’t happen to anyone else.”

A spokesperson for Maven Healthcare said, since the company took on North Court, it had invested significantly in the building and introduced electronic care planning which creates better personal care.

“We are assisting the coroner in every way possible and if necessary will of course implement any lessons learnt from the sad passing of Mrs Sore,” they said.