Marlborough care home makes changes after woman's death

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.

Joan's family had originally moved her into the dementia specialist care home, run by the Order of St John Care Trust, after they felt it would be "safer" for her.

But a five-day inquest held at Wiltshire and Swindon Coroner's Court from November 25 to 29, 2024, found that carers had not re-alarmed the door that the Great Bedwyn local went out of, nightly checks had not been completed, and staff in charge that night were untrained and unqualified.

Joan subsequently died of hypothermia in the care home garden, and pathologists believe she was out there wearing only a nightdress for over an hour.

Joan Chapman was a beloved family member and popular lady in the Great Bedwyn community (Image: Barbara Ellary) "Joan's death was contributed to by gross failings in the management of the care home," concluded the jury.

"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."

Following the inquest, a spokesperson for Coombe End Court care home said: "We continue to send our deepest condolences to Mrs Chapman’s family following her death while in our care.

"We apologise unreservedly for the shortcomings identified during the inquest.

"We are sorry the processes that we put in place to ensure the safety of Mrs Chapman whilst in our care were not followed on the night in question.

Coombe End Court care home has apologised for its failings (Image: Google Maps) "Following Mrs Chapman’s death, detailed actions have been fully implemented to address the issues highlighted during this inquest, particularly regarding staff training, observation procedures, documentation, risk assessments and governance.

"These important lessons have been applied across all of our care homes to ensure that we deliver the very highest quality of care for our residents at all times."

Joan, who lived in Great Bedwyn for most of her life, has been remembered by her family as a "very popular lady" and beloved mother, grandmother and great-grandmother who was well known for her flower arranging and award-winning homemade apple pies.

The family added: "These are difficult findings for us as a family and we will need time to process them.

"We hope the many changes that have been made are a testament to the fact that something like this will never happen again."