A family have spoken of their shock after their loved one lost almost two stone in two weeks during a temporary stay at a care home just days before her death.
Patricia Slaughter went to Ritson Lodge Care Home in Great Yarmouth for a fortnight, while her daughters who care for her went on holiday.
But when her family went to collect her they said they "couldn't recognise" their loved one because of how her health had deteriorated.
She died just days later and an inquest into her death has heard evidence of how her condition had gone dramatically downhill during her stay.
Jacqueline Lake, the coroner, heard that Mrs Slaughter lost 12kg - almost two stone - while at the home.
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A statement read by the family said that when they dropped Mrs Slaughter off on June 5, 2023, she could walk on her own with the help of a stick and could speak well.
But when they collected her on June 23 she was in a wheelchair and unable to speak.
Shortly after returning home, she became severely dehydrated and suffering from kidney damage and was taken to hospital the following day.
The retired factory worker died on June 30, 2023, at the James Paget Hospital, in Gorleston.
Her inquest heard that the care facility had made "numerous errors" in keeping track of Mrs Slaughter's medical records, mainly notes of her food and fluid intake.
Some days the notes on the food and fluid consumption were not completed or were incorrectly filled in.
Mrs Slaughter's family had left some of her favourite Biscotti biscuits and Baileys Irish Cream with her, but staff had not given these to her as it was against the home's policy.
A medical practitioner at the hospital gave the medical cause of death as enhanced dementia, hypertension, frailty and concerns of neglect at the Ritson Lodge Care Home
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A post-mortem analysis gave the cause of death as pneumonia.
With the conflicting conclusions, the coroner heard evidence from the care facility manager and the family before summarising.
Siobhan Fennell, the care home manager, argued that "care had been provided" and said that Mrs Slaughter was a "reluctant patient" because she wanted to go home which made it "difficult" for her staff.
Mrs Lake concluded there was "not sufficient gross neglect" to formally give neglect as the cause of death.
She said she did not hear evidence that the lack of fluid and food intake of Mrs Slaughter was raised to medical professionals.
Recording a narrative conclusion, she said: "Mrs Slaughter died from pneumonia. She was acutely dehydrated when she entered the hospital.
"In the period immediately before this, her intake of food and fluids was poor. This was not always monitored or escalated by the care home."
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Mrs Lake was satisfied that the care home, by adopting a new electronic system to monitor the recordings of patients' food and fluid intake, had made changes to prevent further and similar deaths.
REMAINING ANGER
Though the medical cause of death was not issued as "neglect" the family, speaking after the inquest, expressed "anger" at the decision.
They said: "Pat was a lovely, smart, tidy and caring person. She was a great-grandmother, a grandmother and a mother.
"She was smiley and always playful, with the best interests of everyone else always taking priority before her own wishes.
"But we are very disappointed by the official cause of death decision because we feel that there was more than enough evidence of neglect heard that contributed to Pat's death.
"She was unrecognisable when we picked her up and we really struggle to accept this verdict," the family said.
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