The personal injury and clinical negligence team was instructed by the family of Beryl Varcoe whose tragic death was the subject of an inquest at Surrey Coroner’s Court which took place on 21 and 22 March 2017, with the Coroner providing her conclusion on 28 April 2017.


Following an admission to the Royal Surrey Hospital in April 2013 for treatment of cancer, Mrs Varcoe was referred to Elmbridge Borough Council by the occupational therapy department for the installation of a community alarm due to concerns that Mrs Varcoe might suffer a fall at home and being unable to summon for assistance. 

The alarm was installed by an employee of the council on 13 May 2013.

At the council’s request the alarm was upgraded and a new system put in place on 19 December 2015 by the same council employee. 

In light of mobility difficulties being experienced by Mrs Varcoe, at the time that the original alarm was fitted on 13 May 2013 up until her death, Mrs Varcoe used what had previously been a sitting room as her own bedroom on the ground floor overlooking the garden at the back end of her two-storey property. While at home Mrs Varcoe’s usual practice was to wear the alarm pendant around her neck.

On the evening of 18 April 2016 Mrs Varcoe fell in her bedroom. She repeatedly pressed the pendant but the alarm did not activate. She therefore remained on the floor of her bedroom until she was found at approximately 4pm on 19 April 2016 by a neighbour and members of her family, including her son and his wife. 

Mrs Varcoe was then taken by ambulance to St Peter’s Hospital where she was diagnosed with pneumonia and chest sepsis. She was treated by intravenous fluid and antibiotics but tragically her condition deteriorated and she died at the hospital on 21 April 2016.

The inquest

The inquest heard from one of Mrs Varcoe’s daughters that she had been lying on the floor for some 20 hours pressing the alarm pendant.

The evidence heard at the inquest by a doctor and pathologist confirmed Mrs Varcoe’s cause of death as being lobar pneumonia, and that a substantial period of inability to move whilst lying on the floor would have impacted upon Mrs Varcoe’s condition on admission to the hospital.

The council employee who fitted the alarm stated that he had no recollection of attending Mrs Varcoe’s property on at least two occasions. He did, however, admit that he had not tested the pendant or alarm in the room the furthest away from the unit nor the bedroom or garden of Mrs Varcoe’s home.

The manager of the council employee, admitted surprise that his colleague had not tested in the far room or bedroom as his usual practice for advising the team would be that checks in these places would be required. He confirmed to the Coroner that the council’s practices had changed as a result of this tragic accident and that there were proposals for a checklist to be used by installers when carrying out alarm testing.

The inquest also heard evidence from a representative of the manufacturers of the alarm who confirmed that testing involved making sure that the pendant would send a signal from the furthest point of the property, which may include the garden.

The Coroner’s findings and conclusions

The Coroner concluded that as a direct result of the alarm not working, Mrs Varcoe was not found following her fall. The Coroner found that on admission to the hospital, Mrs Varcoe was diagnosed with pneumonia and septic shock which evidence shows was directly a result of lying immobile on the floor. The Coroner referred to comments made by the doctor responsible for Mrs Varcoe’s care that in light of her condition on admission to hospital she had a poor chance of survival. The Coroner further considered the comment made by the pathologist that the delay had made more than a minimal contribution to Mrs Varcoe’s death.

The Coroner concluded that Mrs Varcoe died from lobar pneumonia and that the time she spent on the floor and the subsequent delay prior to her admission and commencement of treatment made a material contribution to her death.

Prevention of Future Deaths Report (PFDR)

As a result of the evidence heard before her, the Coroner made a PFDR under paragraph 7(1) of Schedule 5 to the Coroners and Justice Act 2009.

The Coroner expressed concerns in her report that the council’s alarm service had a significant number of clients who currently have alarms which may not have been thoroughly range-tested and may not function throughout the entirety of the service users’ homes. The Coroner therefore concluded in this report that the council must take action to prevent future deaths.

Russell-Cooke has been instructed to pursue a case against the council on behalf of Mrs Varcoe’s children and her estate.