Abertillery: Significant failure of care at nursing home, coroner says

Dorothea Hale became malnourished and developed extensive pressure sores at the nursing home

A woman suffered a "significant failure" of basic medical care at a nursing home, a coroner has found.

Dorothea Hale, 75, had two strokes after heart surgery, which left her needing full-time care.

She moved to the Grosvenor Nursing Home in Abertillery, Blaenau Gwent, in July 2006, becoming malnourished and developing extensive pressure sores.

In November 2006 she was admitted to Nevill Hall hospital in Abergavenny and died there in January 2007.

In a narrative conclusion coroner Geraint Williams said Mrs Hale had a number of serious health conditions.

• Abertillery care home resident's inquest told of nurse's shock at care

• More inquests into deaths at Gwent care homes could be opened, says coroner

• Operation Jasmine: Care home failures 'contributed to deaths'

Gwent Coroner's Court heard Mrs Hale's death featured in Operation Jasmine - an investigation into neglect of elderly residents at several care homes in south Wales.

The inquiry lasted years and cost more than £11m, with detectives looking at 63 deaths.

One expert told the hearing in Newport the pressure damage from Mrs Hale's sores was "the worst that he'd seen in over 30 years of professional practice."

A coroner said Dorothea Hale suffered a "significant failure" of basic medical care

The coroner said that not seeking prompt medical advice to help with malnutrition amounted to a "significant failure in the provision of basic medical care".

Two members of the home's staff were investigated by the Nursing and Midwifery Council and were struck off the register after being found unfit to practice.

'Significant failure'

"Mrs Hale developed multiple and significant comorbidities which caused a deterioration in her health and contributed to the development of pressure damage and malnutrition," Mr Williams said.

"The care that she received at Grosvenor Nursing Home, did not prevent the development of those conditions."

Mr Williams found the cause of death not to be neglect but to be a result of her combined medical conditions.

He said there had been a "significant failure" of basic medical care.

The coroner did not issue a prevention of further deaths report.

They are issued when it is the coroner's opinion that action should be taken to prevent future deaths.

"Fifteen years after the death of Mrs Hale, the legislation, regulations, and equally importantly the philosophy and practice of state agencies has changed markedly," Mr Williams said.

He offered his condolences to Mrs Hale's daughter.