Doris Sawyckyj was said to be “as bright as a button” when her son Peter went to see her at The Beacon Intermediate Care Unit. But he returned less than 24 hours later and found her confused, covered in blood and vomit and with a bruise on her chest which has never been explained.

Mrs Sawyckyj was taken by emergency ambulance to Diana Princess of Wales Hospital and her son was present the following morning when she died from multiple organ failure and pneumonia.

Mr Sawyckyj, who lives at Brian Avenue in Waltham, made a formal complaint to the Care Quality Commission (CQC) who asked The Beacon to conduct an internal investigation, which they did. When that was completed he was contacted by the independent adult social work company Focus, and he accepted their offer to carry out another investigation.

The case brought back painful memories of circumstances around the death of Mr Sawyckyj’s father, Stefan, some 12 years ago. This time he instructed Bridge McFarland LLP to explore whether he could pursue a claim for medical negligence. As Mr Sawyckyj waits for answers – and an apology – more than a year after his mother’s death, Mr Sawyckyj wants to raise awareness of the failings which have been admitted by Care Plus Group, the operators of The Beacon.

Mrs Sawyckyj had been treated at the hospital for a chest infection and was transferred to The Beacon on 12 June 2017 for intermediate care prior to going home. Mr Sawyckyj said his mother was fine when he saw her on the evening of 13 June, and at lunchtime the following day he received a call from The Beacon to discuss taking her home.

But when Mr Sawyckyj arrived at The Beacon at about 7.45pm on 14 June he found his mother slipping out of her chair and covered in vomit and blood. He was told she had been like that since 2pm. Paramedics who attended noted that Mrs Sawyckyj was borderline septic and had a large bruise on her chest.

She was admitted to hospital, where a doctor told Mr Sawyckyj his mother would have had more of a “fighting chance” if they had been able to start treatment earlier.

In his letter to the CQC Mr Sawyckyj raised serious questions about the care procedures at the home and asked if it was possible she’d had a fall earlier in the day.

He wrote: “I feel very distressed that mum had been left on her own in a poor condition for so long. They never contacted me to say she was poorly. Also, if I had not visited mum that evening I feel they would have put her to bed and allowed her to pass away on her own. I’m not even sure they would have called an ambulance if I hadn’t asked them to get medical help.”

The report by Focus found there was “little detail” recorded electronically or in the hand-written patient file of the “daily events” of 14 June.

The document said there were “clearly errors of judgment” regarding responding to Mrs Sawyckyj’s “ever-changing condition” and contacting the appropriate health professionals. It also noted the “lack of robust recording of critical matters” such as written and electronic observations.

The report recommended further training and standard setting for a member of staff who was on duty at the time but said that because Mrs Sawyckyj had died no action had been taken regarding risk management or in relation to staff members involved in the event. The report concluded that “an apology should be provided” to Mr Sawyckyj.

A report completed in January 2018 by Care Plus Group repeated the concerns about a lack of detail and said staff at the home would be reminded of escalation procedures in the event of a patient becoming acutely unwell. The Care Plus investigator reported: “I could not find the cause of bruising to Mrs Sawyckyj’s chest as the staff members could not recall seeing any bruising.”

Mr Sawyckyj said: “My dad walked into hospital 12 years ago because he had diarrhoea and sickness. He got MRSA and he came out in a box. We didn’t do anything about it but this time I decided I was not going to let my mum die in vain.

“I sat at mum’s bedside after hearing the outlook was not positive and I prayed it would be over quickly because we went through so much with my dad. But no one has told me how the bruising happened and whether mum had a fall. The reports said an apology should be provided but I’ve never received one. I’m just worried that all of this will happen to someone else if I don’t say something about it.”

Chris Gresswell-Green, a senior medical negligence solicitor at Bridge McFarland LLP and Action against Medical Accidents (AvMA) Panel Member is supporting Mr Sawyckyj through the process of making a formal complaint “It’s very distressing for all the family, Mrs Sawyckyj’s condition deteriorated so much in that 24-hour window and they are still without any real explanation as to how this happened. Care home staff have a duty of care for the vulnerable people they look after, and for a son to find his mother distressed, injured and ignored is completely unacceptable.

I sincerely hope that the Care Plus Group make a full apology to Mr Sawyckyj and his family, and that lessons are learned by them, and all the staff who work at The Beacon.”

Bridge McFarland LLP are happy to provide free initial consultations if you or someone you care about has been affected by poor care standards – we can assist in making formal complaints or bringing legal claims.