Windows at a care home in Croydon were still unsafe four years on from the “sudden and traumatic” death of a man with learning difficulties.

Stephen Verrall, was found in the car park of St John’s Nursing Home after falling from a first-floor bedroom window on October 17, 2017. He died in hospital two days later from his injuries.

The 57-year-old had lived at the nursing home in Hailing Park Road, South Croydon, since 2014.

Inspectors from the Care Quality Commission (CQC) visited the home in October 2021. The targeted inspection focussed on the home’s safety following an inquest into the death of Mr Verrall.

A report published at the end of January 2022 said: “During this inspection we found people continued to not be cared for in a safe environment.

“We identified 27 windows that were not appropriately restricted to ensure people were protected from the risk of falling from height. We also identified a further eight windows that were not appropriately restricted, posing a security risk.”

After the inspection the CQC asked the care home in Hailing Park Road, South Croydon, to prove it had made the windows safe.

It provided pictures which showed all windows had now been made secure to protect residents from the risk of falling from height and leaving without staff’s knowledge.

An inquest into Mr Verrall’s death in September 2021 concluded his death could have been prevented.

After the inquest, his sister Samantha Harlow said: “They failed to provide a safe environment for my brother which resulted in his death. Stephen suffered a sudden and traumatic death which should never have happened.”

In February 2021, the care provider pleaded guilty at Croydon Magistrates’ Court to failing to provide safe care and treatment, resulting in avoidable harm to Mr Verrall while he was resident at the home in a prosecution brought by the CQC.

The nursing home was fined £80,000 and ordered to pay £3,474 prosecution costs, plus a £170 victim surcharge. The case found that the window from which he fell had been restricted by a single metal chain attached by screws to an aluminium frame which had been in place for at least 15 years.

The home was rated ‘requires improvement’ by the CQC in September 2021.

St John’s Nursing Home was contacted for comment.