A fragile 95-year-old woman died of hypothermia and pneumonia after both boosters failed in her & # 39; inadequate & # 39; care center.
Doreen Osborne was found with her temperature 9C under normal after hair that she had been left for three weeks without central heating and vital medication.
Emergency services rushed the retiree to the hospital after she put her in & # 39; a severely subcooled state & # 39; had found in the Pineheath nursing home in High Kelling, near Holt, Norfolk when the temperatures dropped below freezing.
The report from the Norfolk Safeguarding Adults Board revealed that the two water heaters dated from the 1960s and had not been replaced since one year ago failed, despite being condemned in 2013.
Doreen Osborne, 95, was found with her temperature 9C below normal after her house had been without central heating and vital medication for weeks
Employees of the private house had reportedly used temporary heaters and kettles and resorted to the transportation of jugs with hot water from the kitchen to wash residents.
Mrs. Osborne was diagnosed with a chest infection and prescribed antibiotics by a GP who had visited her in November 2016.
But home staff faxed her recipe to the wrong pharmacy, which meant that the medicines were never delivered and her condition quickly deteriorated.
The staff members called 999 after they were delivered the following morning on November 9 at 5.35 am on Ms. Osborne.
Paramedics found her severely hypothermia with a body temperature of 27.5C, about 9C below normal. They also noted that the environment of the house is extremely cold. was, according to the report.
A second ambulance crew was asked to carry out welfare checks at other residents in the home after the ambulance staff were worried about this.
Emergency services rushed Ms. Osborne to the hospital after she put her in a very hypothermic state & # 39; had found when the temperatures dropped below freezing
Mrs. Osborne, who used a wheelchair, was taken to the Norfolk and Norwich hospital by ambulance, where she died the same afternoon.
The owner and manager of the nursing home were interviewed on suspicion of manslaughter by gross negligence, but the complex case unit of the Crown Prosecution Service decided not to take any action against them.
The report showed that the Commission for Care Quality had asked the police files about the case and was still thinking about a possible prosecution in the context of the Health and Social Care Act.
Ms. Osborne's daughter Susan Sampson, 73, from High Kelling, said that her mother used to work as a packer at a Sainsubry store in Wimbledon, South London before moving to Norfolk.
She said: "I blame the care at home for her death. She did not have good heating for three weeks. The boilers were very old and they should have been replaced years ago.
My mother told me that the boilers were broken and she complained that she was cold all the time. She has not showered or washed her hair for the whole three weeks.
Former nursing home Pineheath in High Kelling, near Holt, Norfolk. Employees had reportedly resorted to jugs of hot water from the kitchen to wash the residents
She was depressed and said: "I am freezing cold, I do not know what to do with myself".
I kept going into the office to ask what was going on and they kept saying that they would fix it. Then there were apologies that parts were missing.
They said they had heaters, but I only saw a small portable blower on the day she died.
& # 39; The window in her room was abandoned by a resident with dementia about six months earlier. It was repaired but after that it never went well again. There was an opening of an inch where it was open at the bottom, so there was a constant air flow. & # 39;
Mrs. Sampson said her divorced mother had paid £ 500 a week to live in Pineheath, using money from the sale of her former home in Wimbledon South London.
She added: "I asked her several times if she wanted to move, but she said she had friends there and loved people. But it started to change when they lost a lot of staff and had to use more temporary workers. & # 39;
The nursing home was run by the Essex-based Diamond Care (UK) company before it was closed.
The nursing home or Mrs Osborne was not mentioned in the report, referring only to Mrs E.
But her identity was revealed by documents showing that her death took place in August last year at the Norfolk court.
Norfolk's senior coroner Jacqueline Lake took a narrative conclusion and said she had died of bronchopneumonia and hypothermia.
Ms Lake added, "The evidence does not reveal which was first developed or to what extent the two above points contributed to the death of Ms. Osborne."
The coroner also noticed that the kettles in the house had been broken and that Mrs. Osborne had left without antibiotics.
The house, which was said to be in a "badly insulated building" & # 39; with high ceilings and large rooms, was closed by the owner in May 2017 after inspections of the Care Quality Commission had assessed it inadequate two months earlier.
The problems identified were drafted windows that did not close properly, inadequate safety in an elevator and constant concerns about legionella.
The staff had claimed that temporary heaters were left at night and checks were carried out every 15 minutes to ensure they were warm enough, the report said.
One resident was said to be so cold that they had to be wrapped in a blanket so that a doctor could take a blood sample.
The legionellabug was found in three rooms and new hot water tanks were installed.
The University Hospital Norfolk and Norwich expressed serious concerns on December 12 & # 39; about the residents of the home, amid the fear of infection control and legionella.
The CQC has not contacted the care center, or anyone else, for three days after a family member called on 28 October 2016 with concern.
The Norfolk County Council's research office had heard of a family member's problem on October 31, but did not mention it as a guarantee of concern and sent the adult health care quality assurance team an email just the next day.
Neither the municipality nor the CQC would have checked the tree trunks for the fact that the staff had kept the room temperature
Joan Maughan, chairman of the Norfolk Safestuarding Adult Board, said: "It is clear from this assessment that there were deficiencies in health and safety standards in the nursing home where she lived.
& # 39; Security of Adult Reviews takes place so that we can all learn from what has happened and see what changes may need to be made to prevent tragedies from occurring in the future.
It is therefore particularly worrying that the owner of the care center would not engage in this assessment.
& # 39; Providing sufficient hot water and heating should be one of the minimum expectations in a home that cares for older and vulnerable residents and it is clear that the standards lag far behind what we would expect as a board.
It is, however, important to emphasize that in this case there are some very good practices, especially of the paramedics who visited the house on the day that Mrs. E died.
& # 39; Their quick actions identified the risk for Mrs E and others and ensured that other residents received the necessary health care.
James Bullion, Executive Director of the Adult Social Services Service in Norfolk County Council, said: "The failure of this care center to adequately care for its residents and keep them safe is particularly worrying.
We accept the recommendations of this indemnity for adults and also share the concern of the board that the owner of the house would not participate in this assessment.
A spokeswoman for the CQC said: "CQC was part of the review about the death of a woman who had received care in Norfolk and we are aware of the outcome published by Norfolk Safeguarding Adults Board.
We have investigated what has happened in this case and work together with the local government to ensure that lessons learned from the assessment are learned. Our sympathy goes out to the family of the lady who died. & # 39;