Joy Bentley, of Mildenhall, daughter of Sonia Sore, urges North Court Care Home, in Northgate Street, Bury St Edmunds, to do better after mum’s death

The daughter of a former pub landlady who died after a fall at a care home has urged it to do better after a coroner’s report raised concerns about a ‘cultural problem’.

Sonia Sore died on November 8, 2023, after suffering a brain injury having fallen out of her bed at North Court Care Home, in Northgate Street, Bury St Edmunds, on October 20.

Darren Stewart OBE, area coroner for Suffolk, ruled she died due to accidental causes and the fall made a material contribution to her passing in an inquest on January 23.

A prevention of future deaths report by Mr Stewart, published on Monday, urged the home’s operators Maven Healthcare to take action, as he highlighted a ‘less than diligent focus on risk assessment and mitigation’.

Maven said it had made ‘significant improvements’ to the home since acquiring it from former operators Four Seasons in January 2024, shortly after Mrs Sore’s death.

Joy Bentley, of Mildenhall, Mrs Sore’s daughter, said her mum’s friends still lived at the home and she hoped North Court would learn from her death so ‘nobody else has to go through’ the same experience.

“I totally expect they will look at their training and systems,” Joy said. “My concern is this will just be another paper exercise.

“I feel that they’ve let my mum down, they’ve let us down, they’ve let her grandchildren and great grandaughters down. They should have done better.”

Mrs Sore ran The Volunteer Arms, in Mildenhall, with her husband Donald for 16 years from 1976.

She was also mayoress of Greene King Licence Society and a carer at a Newmarket residential home. She moved into North Court in 2017 and broke her hip in a different fall in 2020.

The fall at the home on October 20, 2023, was Mrs Sore’s second in the space of a week, following the first on October 14.

Her care plan had been updated to say both rails on her bed should be raised, but Mrs Sore expressed repeated objections.

The inquest and report said the update was not actioned, meaning she was able to fall out of bed for the second time on October 20.

The report said despite risks being assessed and mitigation measures identified, staff regularly failed to implement them.

It said: “In Mrs Sore’s case, this included the failure to secure the right hand side bed rail, as identified in numerous risk assessments relating to mitigating her risk of falling from the bed.

“The evidence indicated this applied in relation to the actions of multiple staff at the care home, not just a few, giving rise to the concern this was a cultural problem at North Court Care Home.”

Joy said, if the home had talked to her, she would have been able to convince her mum to have her bed rails up.

“My mum was a strong, independent person with her own opinions,” she said. “However, she was a nurse once upon a time. She would have known, in that setting, you have to adhere to safety first.

“If they (the home) had talked to me, I would have persuaded her to make sure the bed rails were up.

“Mum didn’t like to trouble us, she knew we had busy lives. She just wanted to blend in and be liked and not cause a fuss. It breaks my heart, 18 months down the line, what has happened.

“She’s left a big, big gap. They need to make sure this does not happen to anyone else.”

Joy said she had her concerns about the home and had considered trying to move her mum to a different one, having several conversations with her brother about it.

However, she said Mrs Sore loved living at North Court, where she had many friends and loved the staff.

When she returned home from hospital after the second fall, Mrs Sore was ‘welcomed back like the Queen’, Joy said.

Maven Healthcare was ordered to respond to Mr Stewart within 56 days of the issuing of his report, detailing the action it has, or proposes to take, along with a timetable.

A spokesperson said: “We extend our continued condolences to her family and loved ones.

“Since the acquisition, we have made significant improvements at North Court, including: Investing in the refurbishment and safety of the building; ending reliance on regular agency staff by recruiting and developing a stable, skilled team; introducing electronic care planning to support more efficient, person-centred care; strengthening our quality assurance processes through regular internal audits and feedback from external professionals.

“These efforts have already led to noticeable improvements in care quality, culture and team engagement.

“In full co-operation with the coroner, we are finalising a Regulation 28 response that outlines the specific measures taken to prevent a similar incident from occurring again.

“We remain fully committed to transparency, learning, and continuous improvement – and will continue to support the coroner’s process in every possible way.”