The family of a farm worker who died a fortnight after care home staff delayed calling 999 said they should have been “listened to".
Geoffrey Whatling, from East Winch, was temporarily staying at Amberley Hall in King's Lynn for rehabilitation after an operation when his condition began to worsen.
An inquest into his death heard that on April 8 last year, his family noticed he was becoming increasingly unwell with a lowered temperature of 34.4C and urged care staff to alert emergency services.
The family shared their concerns with Amy Thurling, then a team leader at the home, who assessed him and phoned 111.
But the court heard there had been confusion around his NEWS2 score - a metric used in medical professions to assess the severity of deteriorating patients and guide future care.
It heard Ms Thurling had assessed him on this scale as having a score of five - which requires regular observation - but the home's electronic system calculated it as a seven, requiring a 999 emergency response.
Later that day, Vera Luse, who had taken over from Ms Thurling, spoke to a GP from the 111 service, but admitted to the court she had not taken on board his suggestion Mr Whatling may be suffering with sepsis.
Two days later, one of his daughters visited the home and found he had continued to deteriorate and raised the alarm with staff again.
This time 999 was called and he was taken to hospital - where he died on April 26.
Sylvia Whatling, the 82-year-old's wife, said: "On the morning of April 10 there were five members of staff on his ward and not one of them thought to check on him. We believe he would have been left that way.
"Geoffrey was not one to complain and would say he was okay even if he was not - they should have noticed [his deterioration].
"His death could have been prevented and he could have come home - we all believe this."
Mrs Whatling said the family were already concerned with the standard of care the retired farm worker received during his stay at Amberley Hall - which is rated as inadequate by the Care Quality Commission.
She said that on one occasion the family had found Mr Whatling in soiled sheets and that staff had told him they "did not have time" to take him to the toilet.
AN 'UNUSUAL STEP'
Mr Whatling's death saw Jacqueline Lake, Norfolk's senior coroner, warn that future deaths could occur if the home did not take action to address several concerns about Mr Whatling's care.
But in what she described as "an unusual step", the report was issued ahead of the inquest being held.
Mrs Lake said: "I took this unusual step because I was not satisfied from the home's first statement that the concerns the events raised had been noticed and acted upon."
Ula Jakoniuk, deputy manager of the care home, told the court that a number of changes had been made as a result of Mr Whatling's death including improving the level of training that staff receive and how it keeps record of observations on residents.
Mrs Lake concluded that Mr Whatling's death, due to an exacerbation of chronic obstructive pulmonary disease, was a result of natural causes.
Mrs Lake did not conclude, however, that the delays had caused or contributed to Mr Whatling's death.
'FAMILIES NEED TO BE LISTENED TO'
Following the inquest's conclusion, Mr Whatling's daughters issued the following statement:
"We are glad we have highlighted the failings in our dad's care but it is a shame it took his death for Amberley Hall to make changes to prevent future deaths.
"It should not have taken us to demand a 999 call - this should have been done sooner by staff.
"Most of his observations were not recorded and were missed.
"Family members need to be listened to. If they think something is wrong, appropriate steps need to be taken."
'OUR UPMOST PRIORITY'
A spokesperson from Amberley Hall offered their "sincere condolences to the family and loved ones" of Mr Whatling.
They added: "We offer our deepest sympathies.
"The safety and well-being of our residents is our utmost priority.
"Additional training recommendations have been implemented across the company. We continually review and enhance our care practices based on feedback, regulatory requirements, and best practices in the sector.
"We will carefully examine the coroner's findings to identify any areas where we can further improve our services.
"We note the coroner’s inquest has determined that Mr Whatling’s death was from natural causes."
Comments: Our rules
We want our comments to be a lively and valuable part of our community - a place where readers can debate and engage with the most important local issues. The ability to comment on our stories is a privilege, not a right, however, and that privilege may be withdrawn if it is abused or misused.
Please report any comments that break our rules.
Read the rules here