A review into the death of my elderly mother (Sheila Hartman), who regular readers of my personal blog will remember was brutally beaten by another resident in her Bedfordshire care home, has concluded that the attack might have been prevented if only her bedroom door had been closed at night.
Sheila died in hospital shortly after being hit multiple times around the head and body with a walking stick wielded by another elderly female resident who, because of her advanced dementia, thought my mum was an intruder in her own home. A jury inquest into mum’s death heard how the care home, Ridgeway Lodge in Dunstable, should have done more to protect both women. The inquest concluded in October 2024.
Now an independent Safeguarding Adults Review, which could be completed only once the inquest was over, is making a number of recommendations to reduce the risk of resident-on-resident violence in future. The recommendations include:
- Routinely closing residents’ bedroom doors at night unless they or their families specifically request them to be left open as they are in many care homes to facilitate nighttime checks.
- National standards and better resourcing for dementia care in England.
- Tighter registration and inspection procedures.
- More thorough pre-admission checks to ensure potential residents are suitable for open plan care.
- Better cooperation between families, care providers, local authorities and the NHS when risks escalate.
The report, authored by Dr Sheila Fish, was launched on Monday, April 27th 2026. Dr Fish said:
“Sheila and *Barbara’s1 families had both sought a place that could provide their respective mothers with the care and support they needed as their dementia progressed and where they would be kept safe. Both women became victims in a breakdown of these arrangements. Sheila lost her life in a brutal and traumatic way, a memory her family live with. Barbara’s life and legacy was also changed irredeemably, her family carrying a double burden. This review aims to learn from this tragedy.”
I welcome Dr Fish’s report and thank her for her diligence in investigating the wider issue of resident-on-resident harm. My mother was a hugely practical woman, always looking to help people and to solve problems. So she’d be encouraged to hear that the report suggests a number of practical ways that care for those living with dementia can be improved, reducing the chance of something like this ever happening again.
For me the number one recommendation is shut that door. Nobody in their right mind would leave their hotel bedroom door wide open at night. It wouldn’t be safe and it wouldn’t be dignified. Yet care homes routinely do just that because they say they can keep an eye on residents more easily which is nonsense because you can’t properly check on someone’s health and wellbeing from a distance.
Simply closing bedroom doors at night, I believe, is practical, affordable and achievable. Even the most basic of hotels these days manage to allow guests to access their own rooms effortlessly, allow staff access to all rooms yet keep unwanted guests out. The technology already exists.
Dr Fish’s report is receiving widespread media attention. Here’s a selection of radio and television interviews I’ve given in response to the safeguarding review. If you’re interested I’ve also for ease of access gathered all the coverage in one place.
* Barbara is not the attacker’s real name. The report’s author agreed to use a pseudonym to respect the family’s wish for privacy.