A coroner has launched a scathing attack on a care home after an emaciated pensioner was admitted to hospital weighing less than five-and-a-half stone.
Just five weeks before, 'sprightly' 94-year-old Molly Darby had walked into a privately-run care home in good physical health.
But she deteriorated to such an extent at the Beeches Residential Care Home, in Wath-on-Dearne, South Yorkshire, that she was taken out on a stretcher and died shortly after.
When she was admitted to hospital as an emergency case her family claimed she resembled a 'concentration camp victim'.
Staff nurses were shocked to find the widowed mother-of-six had a chest infection, pneumonia, pressure sores, septicaemia and ear and urinary infections. Staff thought she would not make it through the night but she survived for another two and a half weeks.
Rotherham coroner Nicola Mundy yesterday said: 'I find it very alarming that such a vulnerable person who relied on professionals for her care and support was presented to hospital in the way she was.
'The vulnerable in our society must be properly cared for on all levels and their dignity protected. I think that Mrs Darby was not afforded the care and dignity she deserved on this occasion.'
Nurse Julie Norton who received Mrs Darby on a general medical ward at Barnsley District Hospital said: 'It was quite upsetting. She was really, really frail. There were some issues we were really concerned about.
'When I was changing her bedding with another nurse we were all quite upset and distressed. Her right ear was impacted with ear wax and she had a pressure sore, her hair was thin and wispy and badly stuck to her face and neck and her eyes were completely shut. It took quite a lot of bathing with water to open them.'
When old peopleís matron Karen Sharpe saw Mrs Darby she immediately contacted social services.
Endocrine specialist Dr Elizabeth Uchegbu, who examined Mrs Darby, reported: 'She appeared neglected and unkempt, there was a discharge from both eyes, a smell of urine and she was distressed. She was covered in faeces when she first arrived.'
Deterioration: Jim Darby, 72, at his mother's bedside in 2007. The retired miner said Mrs Darby was 'sprightly' when she entered the home
The doctor wrote later: 'I got the impression she was neglected. She was weak and thin and it could not be explained.'
Tissue viability nurse Tracy Green, who carried out an investigation after Mrs Darbyís death, said there were no notes about her pressure sores yet Molly was at 'high risk' of skin damage.
'I believe there had been neglect by omission,' she said. 'This is in the absence of any proof that there was any intervention.'
The Rotherham hearing was told Mrs Darby had a lower than normal body mass index and had been assessed at risk of malnutrition four months before she went into the home.
Her son Jim Darby, 72, a retired miner, told the inquest his mother was 'sprightly' when she was at home in West Melton, near Rotherham.
'Her carers used to say my mum could get up the stairs better than they could,' he said.
But the great-grandmother developed dementia and needed 24-hour care so her family decided to put her in the Beeches. She went into the home on July 6, 2007.
Failings: An inquiry found the widowed mother of six suffered unintentional abuse through 'neglect by omission'
Mr Darby said: 'They kept saying they were feeding her and I had no reason not to believe it but it turned out it was wrong. The nurse at the hospital said she had never seen anybody come into hospital from a care home in such a bad state.'
The former care home manager Julie Morgan said in a statement that staff helped Mrs Darby with her personal hygiene and toileting, but her diet was poor and she would often refuse to eat.
Care assistant Michelle Burkinshaw told the inquest the elderly patient had mobility problems and she was refusing food and fluids. She regularly washed her, bathed her eyes and put cream on her sores.
Pathologist Dr Caroline Quincy said Mrs Darby died on August 29, 2007, from broncho-pneumonia contributed to by coronary artery atheroma.
She said her reduced mobility could have played a part in increasing the risk of pneumonia and there was also evidence of malnourishment.
The 44-bed Beeches was run by the Winnie Care Group at the time of Mrs Darby's death but last year it was sold to new owners MHA. An inquiry by Rotherham Councilís social services department found the previous owners negligent by 'omission of care' for Mrs Darby in February, 2008.
Moira Ockenden, area manager of the Beeches at the time, denied Mrs Darby was emaciated. In a letter to the family read at the inquest she said: 'The references to a concentration camp victim are unjustified.'
She said staff claimed to wash or bathe Mrs Darby on a daily basis and they regularly brushed her hair. The widow had a poor appetite and would refuse food, she said.
She admitted the old woman had sores on her heels, right hip and lower spine when admitted to hospital and that she should have been referred to a dietician.
Sam Newton, Rotherham Councilís safeguarding service manager said an inquiry found Mrs Darby had suffered abuse through 'neglect by omission' but it was not intentional.
'It was based on poor recording, little or no evidence in respect of the care she was receiving, there were no weight charts, fluid or diet recordings and there was no evidence of professional visits.'
Tom Parramore, service manager for the current owners of the Beeches said all the staff were now fully trained and there was regular auditing of residentsí hygiene, nutrition and medication needs.
Cause for concern: The Beeches Residential Care Home, in Wath-on-Dearne, South Yorkshire, has been taken over since Mrs Darby's death, but former operator Winnie Care still runs other homes
Recording a narrative verdict the coroner said: 'Her basic care and medical requirements were not satisfactorily met and her decreased mobility during her time at the Beeches increased her risk of developing a chest infection.'
Ms Mundy went on: 'Her nutritional status compromised her ability to cope with the effects of the chest infection, the latter of which led to her death.'
After the hearing, Mrs Darby's granddaughter Pearl Green, 56, said: 'The coroner confirmed everything we knew as a family. Neglect did contribute to her death. The care she was provided with in that place was absolutely disgusting. It was inhuman.'
Mrs Darbyís son Ray, 68, said: 'Her life was shortened by this. There was a total lack of care. She hardly saw a doctor in 40 years before she went into that home. She did all her own shopping and was very active for her age.'
The coroner is also writing to Winnie Care, which still operates other care homes, asking them if they have reviewed all their procedures, documentation and training following Mrs Darby's death.
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