DRESSED in his typically dapper clothing, 82-year-old George Mason slipped out of Admirals Reach nursing home unnoticed and wandered into the night.
By 10.40am the next day the dementia sufferer was found drowned in the River Chelmer more than two miles away, leaving his devastated daughter demanding answers.
Despite a coroner on Friday concluding staff failed to act on the patient's prolific history of absconding and failure to complete urgent forms correctly, Amanda Malin says the verdict has not offered much closure.
"I can't bring him back, that's all I can say," said the 49-year-old of Maldon Road, Great Totham.
Following a three-day inquest ending last week, her legal team composed a list detailing no less than 23 failures by the Bupa-run Chelmsford home.
"It should never have happened, they are totally at fault. I just hope they learn from what has happened to prevent it ever happening again," said the mother-of-two.
"What happened for me is the worst thing you could ever go through.
"When you know someone you love so much has drowned, especially in the River Chelmer, when I have to go over it every few days, to know that he was in that river face down, it brings back memories.
"I still haven't come to terms with it."
Mrs Malin moved her father out of Purbeck Court retirement flats in Great Baddow in July 2013 after he managed to wander as far as Maldon.
"He'd walked in ditches, out of ditches and was found having a cup of coffee in Quest, the Vauxhall place. That's when I rang around the homes," said Mrs Malin.
After more than three months spent at Totham Lodge residential home, she moved him to Admirals Reach Residential and Nursing Home on October 11 last year upon the advice of Essex social services.
As his dementia worsened his wandering increased, and continued at least three times in the space of a week at Admirals Reach.
Nonetheless her legal team claims Bupa did not adhere to its own missing persons policy by failing to observe him closely in the 72 hours following an escape attempt and failing to notify the Care Quality Commission and the county council of an abscond.
Btween 7.10pm and 7.30pm on Saturday, October 19, Mr Mason went missing from the home's Benbow House, on the same night three senior managers, the unit manager and deputy manager were "off".
The next day a canoeist found him floating in the river in Chelmer Village behind the Fox and Raven.
Since the incident Bupa claims it has installed security pads inside rooms in Benbow House.
Only in July 2013 the CQC found the home was failing to protect residents from abuse and harm.
"The care in the community has gone out of the window I'm afraid, that's how I feel, especially on that night," said Mrs Malin, who with her lawyers want staff properly trained more than anything.
Admirals Reach was one of 21 care homes signing up to a £450,000-funded pilot scheme last month which aims to better train staff.
Hodge Jones & Allen lawyer Julie Say, who along with Jim Robottam of 7 Bedford Row represented Mrs Malin at the inquest, said: "All too often we are hearing of care home failures.
"That anyone in their later years should not be afforded the respect and dignity of a safe environment to live is simply not acceptable."
Deputy assistant coroner for Essex Ellen McGann ruled Mr Mason died as a result of an accident, but stopped short of making recommendations to the home.
With the inquest proceedings over, Mrs Malin will now spread his ashes in the Isle of Man.
The former lorry driver, born in Park Avenue, Chelmsford, loved motorbikes, and in the 1950s and 60s rode a side car in the Isle of Man TT races with Derek Yorke.
"Our residents' welfare is always our number one priority"A BUPA spokesman insisted Admirals Reach staff had learnt from the incident by installing security pads inside the rooms and "strengthening our risk assessments".
During the inquest George Mason's daughter Amanda Malin described Benbow House, one of five purpose built houses, as more like "an institution".
When she visited him with her partner about three days before he was found drowned, she said her father was allowed to walk around without his glasses.
The home in Ridgewell Avenue consists of 158 rooms, with those in Benbow House dedicated to dementia patients.
A spokesman said: "We work hard to balance our residents' desire to be independent in their home with the need to be secure. Our residents' welfare is always our number one priority.
"We have made changes to our code-operated entry doors, reviewed all care plan documentation, and strengthened our risk assessments to ensure we understand the needs of individual residents.
"The coroner is satisfied that the home has taken all appropriate action.
"This was a tragic accident and we would like to again send our condolences to Mr Mason's family."
A spokesman for Essex County Council, the authority responsible for safeguarding the elderly, said: "The council carried out a full investigation in the aftermath of Mr Mason's death and continues to work closely with Bupa in an effort to improve the quality and safety of its care services."
![Bupa care home at fault for death of drowned dementia sufferer George Mason]( "Bupa care home at fault for death of drowned dementia sufferer George Mason")
