A nursing home in Watford has been condemned for allowing a 91-year-old woman to die in pain and covered in horrifying bedsores.

Gwendoline Hoar died while a patient at River Court Nursing Home, in July 2007.

An inquest into her death was held this week and heard Mrs Hoar had been admitted to the home in February 2007.

However, just five months later, with her back, hips and feet covered in agonising and sometimes untreated ulcers, Mrs Hoar died.

A post-mortem found she died of bronchopneumonia on July 12. However, the coroner concluded the terrible bedsores, also known as pressure sores, contributed “significantly” to her death.

The sores were later found to be grade four – the most serious – with some of the wounds so deep they went down to the bone.

At the end of the two-day inquest, the coroner condemned the nature of treatment offered to Mrs Hoar at the Bupa home and criticised the levels of care and form filling in the Tolpits Lane home.

The coroner, Graham Danbury, told Bupa managers he found the level of care provided to the 91-year-old as “seriously disturbing”.

The inquest, held on Tuesday and Wednesday, heard evidence from 13 witnesses.

The court was told Mrs Hoar suffered from dementia and was a resident in the Hampermill House unit of River Court. At the start of her time in the home she could sit in the communal lounge and eat, but she was doubly incontinent and required round-the-clock care.

After concerns were raised about the level of care on the ward, a Tissue Viability Expert, or skin expert, for Bupa was sent to the home to check the patients.

Ann Moore told the coroner she was shocked by what she found on her visit on May 31.

Ms Moore said: “I found a frail little lady in her room who appeared quite undernourished.

“She was very dehydrated her skin was very dry.

“I could see she hadn’t been turned frequently, infact she hasn’t been turned at all according to the documentation.”

She found several more wounds on Mrs Hoar’s body than had been recorded by carers, with some covered in a dressing but others not treated at all.

Ms Moore also told the court Mrs Hoar’s pressure relieving mattress had not been fitted properly.

The mattress, which is fitted with deflating and inflating chambers, had been over-inflated, meaning she was not being rotated.

Two district nurses were then called in to assess Mrs Hoar.

One told the coroner on Tuesday there were so many pressure sores on Mrs Hoar’s body she could not list them all.

Both said they were “shocked” by how serious her condition was.

The inquest heard Mrs Hoar had been a victim of a catalogue of errors, with all the staff who directly cared for Mrs Hoar called to give evidence.

The coroner concluded they had not treated her wounds properly and had not made managers aware of her deteriorating condition.

Even when district nurses – by this time called in to treat Mrs Hoar – recommended a mechanical syringe driver be installed to give her round-the-clock pain relief, management at the home resisted.

A syringe driver was eventually installed on July 10, two days before Mrs Hoar’s death.

A post-mortem discovered Mrs Hoar had developed the bronchitis that eventually killed her because of the immobility caused, in part, because of the pressure sores.

After recording a narrative verdict, Mr Danbury said: “I have to say that in many respects I find the evidence seriously disturbing – evidence about the level of care to Gwendoline Hoar and the levels of supervision of the care given.

“I was struck by a comment by Maureen Collins (clinical services manager at the home) that in her opinion 95 per cent of pressure sores can be prevented.

“I was struck by the fact that the three managers from whom we have heard were shocked by the results of the Tissue Viability Nurse’s visit on May 31.

“It is also a concern that after the visit, when the severity of the sores was at last realized, the level of record keeping was inadequate.”

He concluded by saying: “I was also concerned that at the end of her life the most effective means of offering Gwendoline Hoar pain relief was not delivered.”