A resident choked to death because the care home was short staffed due to the Tour de France being held in England, an inquest heard.
The hearing into William O’Connell’s death heard that some staff had been unable to travel to work at the error riddled-Alexander Court Care Home on public transport due to the world famous sporting event.
This meant the 85-bed home in Harrogate, North Yorks., was two staff short on Sunday July 6, 2014, when 76-year-old Mr O’Connell died.
The home was left with just three carers and two nurses covering the workload usually met by seven or eight members of staff.
The inquest heard that Mr O’Connell didn’t wear dentures and staff had to mash his food up for him.
He was being fed in an arm chair in the dining room and around five to ten minutes after he had finished his meal the senior nurse noticed he was slumped and had started to change colour.
Staff called 999 and tried to resuscitate him using CPR but he was pronounced dead by paramedics.
An inspection in March 2014 by the Care Quality Commission (CQC) found a catalogue of errors at the care home – which charged between #550 and #725 per week.
Residents were at risk of malnutrition and the home failed to ensure people’s safety and welfare.
Nurse Mirela Tibuleac told the inquest at Harrogate Magistrates Court that it was her first shift as a qualified nurse on July 6, when Mr O’Connell died.
She said: “We couldn’t supervise the residents properly and do the rest of the tasks.
“We tried to call for other staff but none came because how would we transport the staff?”
Ms Tibuleac had worked as a carer at the home since January 2013 after moving to the UK from Romania a few months earlier.
Coroner Rob Turnbull asked staff who had worked at the home if changes had been made at the care home following poor CQC inspections earlier in 2014.
Staff contradicted one another with Ms Tibuleac saying: “There were no changes, some to medicines but nothing major.”
However the senior nurse who was on duty, Lynn Reyes said: “There was a lot of changes, from falls to medicines and assigning different jobs.”
The home’s former manager Rebecca Monareng told the inquest that staffing problems stemmed from losing several key members of staff within a few weeks of one another in early 2014.
“That lead to the downward spiral as it were,” Mr Turnbull said.
Speaking about Mr O’Connell’s death, Mrs Monareng said: “It was shocking when it happened, that is why it panicked the staff, when they called me there was panic she was quite shaken.”
The solicitor representing the CQC, Elizabeth Dudley-Jones, questioned Mrs Monareng’s account that she had told CQC inspectors about the unexpected death when they arrived for an unannounced inspection on July 8 and 9.