An angry family has slammed a ‘chaotic’ care home after a 98-year-old gran ‘wasted away’ and died weighing the same as a small child.
Winifred Burns died of chronic constipation at a nursing home where residents “were treated like numbers without dignity and respect”, an inquest heard.
She was left to die alone in her room and in pain in February 2015 at a home where she had been transferred three months before, it was said.
At the time of her death Mrs Burns weighed just 31kg (68lb) which is about the same as a nine-year-old girl.
Her weight had dropped from 38kg within a matter of weeks.
Winifred’s care home had been failed by inspectors and was under investigation by care officials.
The coroner acknowledged that Ponsandane nursing home in Penzance, Cornwall, had been “chaotic” at the time.
But in her ruling at the hearing in Truro she said there was no “intentional” neglect.
Speaking after the inquest daughter Debbie Jackson and Winifred’s granddaughter
Hayley Brown, said she had simply ”faded away” after being moved to the home.
Mrs Jackson said she found it difficult to understand that her mother received the full adequate care she was entitled to when she had wasted away within weeks.
She said: “Mum had such a twinkle in her eyes. She was terrified of being alone, which is why she absolutely loved being with people.
“She should have been looked after much better,
She was 98 and was not going to live forever. But she should not have died alone and probably in pain like she did.”
The inquest heard Mrs Burns suffered chronic constipation, which may have built up over weeks leading to her death, but remained undetected and acted upon.
Recording a natural causes conclusion, coroner Emma Carlyon said she was satisfied that neglect was not a contributing factor in Mrs Burns’ death.
But it was revealed that the nursing home had been under investigation over safeguarding issues for at least twelve months prior to Mrs Burns’ death.
This was reinforced when the Care Quality Commission (CQC) inspected the home and failed it, recommending several urgent improvements to be made.
Julie Barton, the manager of the nursing home, who took over the role weeks after Mrs Burns’ death in 2015, told the inquest that a “negative culture” existed among staff at the time.
She said: “There was a negative culture where staff treated residents like numbers and not like people with the dignity and respect they deserved.
“The staff who didn’t meet our new work ethics were dismissed and those who stayed and were not part of that culture flourished.
“It has taken a lot of hard work but the home is now a happy place.”
The coroner was told that the laxatives and special food supplements she was prescribed at St Mary’s Haven stopped after her transfer to Ponsandane.
A pathologist said her constipation was so acute that it might have built up over days and weeks, leading to a large bowel infarction.
In turn it led to a twisting of her bowel, which then compromised her blood supply.
The inquest heard how her chronic constipation might not have been easy to identify because there was still some bowel movement.
The finding led to Dr Carlyon accepting that there was no intentional neglect involved in her death.
She said: “I didn’t find that neglect was a contributing factor to her death and it is more probable than not that Mrs Burns died of natural causes.
“I was saddened to hear how chaotic things were at the nursing home at the time of her death.
“I am re-assured at how things have changed and how the culture has changed and it is now a happy place.
”I am reassured to hear that improvements have been made and continue to be made.”
Jon Edgecumbe, the chief operating officer at Swallow Court group, which runs the care home, said: “Concerns raised after Mrs Burns’ death were reviewed and acted upon. We worked with the CQC and Cornwall Council to make the required improvements.
“Since the safeguarding issues of 2015 we have worked to minimise the risks to residents. It was a chaotic time, the staff were good people struggling against the circumstances. Ponsandane is now a happy and warm home.”