The ‘gross failings’ of a care home in Wiltshire, run by 'untrained staff' with little knowledge of safety procedures, is found to have contributed to the ‘avoidable’ death of a beloved mother.

In the early hours of January 7, 2022, 96-year-old Joan Chapman was found dead in the garden of Coombe End Court Care Home in Marlborough, after it’s believed she unlocked a door and walked outside, unnoticed, in sub-zero temperatures.

A five-day inquest held at Wiltshire and Swindon Coroner’s Court from November 25 to November 29 found that several failings on behalf of the care home significantly contributed to her death.

The Great Bedwyn local, who enjoyed gardening, baking, and attending church, first moved to Coombe End Court’s specialist dementia unit in 2019 as her family felt it would be “safer” for her.

The Marlborough care home is run by the Order of St John Care Trust and specialises in dementia care.

But the area coroner and a panel of 11 jurors heard how on the night of Joan’s death, the alarm on the door she went out of had been disabled after another resident had gone out earlier in the night and the carer had not reset it.

Joan Chapman died of hypothermia in the care home gardenJoan Chapman died of hypothermia in the care home garden (Image: Barbara Ellary) Joan's death was concluded as hypothermia with dementia as a contributing factor.

But returning a narrative conclusion, the jury said: "Joan's death was contributed to by gross failings in the management of the care home.

"Failings included not locking the external door, not reactivating the external door, failing to complete the night security checks, insufficient training in place for night care staff, a failure to monitor the door and lack of communication between staff on duty.

"Without these gross failings, the deceased would not have been able to exit the door and if the alarm had sounded then care staff would have found her and returned her to her room before hypothermia set in."

Naomi Chipperfield, who was the nightshift leader in charge when Joan died, told the court she had never received training specific to Coombe End Court care home and believes she should have.

She had also not seen the security policy.

“She stated she wasn’t suitable to be there in the role on her own and she had asked around Christmas time for more training," said area coroner Ian Singleton.

“She only moved into care in August and didn’t have her level two certificate. She didn’t know the alarm had been activated at 10.24pm as she hadn’t heard it.

“Naomi didn’t know she had to do a head count and she had not seen the security policy.

“After Joan’s death, she said pressure was put on her by more senior staff to sign paperwork -  a claim which those staff deny.”

PC Alexander Bell, who attended the care home on the morning of Joan’s death, also noted that the doors were not difficult to open and could be unlocked without a key by twisting.

A tick sheet submitted to the court recorded that each resident’s room had been visited at two-hour intervals throughout the night leading up to Joan's death.

However, some marks were later crossed out by carers.

Joan, who lived in Great Bedwyn for most of her life, has now been remembered by her family as a "very popular lady" who was well known for her flower arranging and won many awards for her homemade apple pies.

Changes have since been made at care homes owned by the Order of St John Care Trust, including moving from paperwork to electronic systems, improved training and better checks.