GROSS deficiencies led to the death of a 92-year-old Handforth man, a coroner has found.
Bill Stone, a former resident at Southfield Manor, walked into the Styal care home in February 2006, a relatively, physically healthy man despite suffering from Lewy body dementia.
But an inquest heard that when grandfather Mr Stone left three months later, he was malnourished, dehydrated and had badly infected bed sores on his arms, legs and buttocks.
An experienced nurse told the hearing that he had some of the worst bed sores that she had ever seen.
Cheshire County Council has since moved all of its patients from the nursing home following an inspection sparked by Mr Stone's death on June 1, when staff at Manchester Royal Infirmary contacted the inspectors with their concerns.
Recording a verdict of death by natural causes Cheshire coroner Nicholas Rheinberg said there had been "gross deficiencies" in Mr Stone's care and listed negligence as a contributory factor.
He said: "I find that had Mr Stone had proper and timely care, he would not have died when he did."
Mr Rheinberg told the family he intended to write to the Commission for Social Care Home Inspection to recommend a follow up visit to Southfield Manor.
Mr Stone's only daughter 53-year-old Pam Finn, of Norbreck Avenue, Cheadle, said after the inquest the family would now consider taking legal action over her father's death.
Summarising the evidence heard at an earlier hearing at Macclesfield Town Hall, Mr Rheinberg said: "How did the situation arise whereby an elderly patient in the care of a nursing home should have been admitted to hospital with the worst pressure sores an experienced sister had ever seen?"
Retired butcher Mr Stone lived with his wife, Flo and their daughter Pam at Spath Lane in Handforth.
Following his wife's death, he began to suffer from dementia and spent some time at The Hawthorns residential home in Wilmslow before being moved to Southfield Manor when his condition progressed.
Relatively healthy, his daughter said he walked into the home under his own steam and always looked well dressed and clean when she paid a regular weekly visit.
The inquest heard that over the next three months, Mr Stone had a bout of flu and began to loose weight.
The care home's GP, Dr Wai Chung, was called to look at pressure sores on his foot and other ailments over the next few weeks.
A tissue nurse Hilary Miller, was also called and inspected only his foot. She admitted she did not know of or find any pressure sores on other parts of his body.
Mr Rheinberg said: "Although by her own admission she should have examined other areas, the fact that she was not told of the others indicates a deficiency in the care given by the staff at Southfield Manor."
After booking an appointment for Mr Stone at MRI orthopaedic clinic, the inquest heard neither Dr Chung nor the tissue nurse visited Mr Stone again.
A nurse at the home, Sayed Ali, said he questioned Dr Chung about waiting ten days for an appointment but was told this was standard.
By the time he reached MRI, his sores were so bad that the inquest heard amputation was the only option, but doctors ruled he was too ill to undergo the surgery.
He died on June 1. A post mortem revealed the cause of death as a severe blood infection, infected necrotic pressure sores, bronchial pneumonia and a progressive brain disease.
A subsequent investigation by the care home inspectors found notes and care plans for Mr Stone were either incomplete, badly filled in or not acted upon.
READ the family's full reaction ion this week's Express ...
