A pensioner died following a fall at a nursing home in St Austell, an inquest has heard.
Just weeks after the death of Clinton House resident Ronald Hunt, the home, operated by Morleigh Group, was deemed to be understaffed and failing to meet the needs of its residents.
Today an inquest, held at Truro Coroner's Court, heard Mr Hunt died from bronchopneumonia two weeks after he fell at Clinton House, Truro Road, on the evening of July 7 2013.
Registered nurse Gary Howard told the court Mr Hunt fell in a communal lounge of the home, which was unsupervised at the time.
During the fall the pensioner, who suffered from dementia and had a history of falls, lost responsiveness and fractured his neck and leg.
He was taken to Royal Cornwall Hospital, Treliske, and returned to the home 11 days later for end of life care.
On August 13 2013, less than a month after the pensioner’s death, the Care Quality Commission (CQC) carried out an inspection at Clinton House.
The health and social care watchdog, which prevented the home form accepting any new admissions following the inspection, reported: “There were not always enough qualified, skilled and experienced staff to meet people's needs.”
The report continued: “The current staffing levels mean that people's needs are not always being met in a timely manner, meaning they may be at increased risk of pressure area damage, falls or weight loss.”
Pathologist Juliane Stolte recorded the primary cause of Mr Hunt’s death as bronchopneumonia.
She listed the fall, which resulted in fractures to the neck and femur, and vascular dementia as secondary causes.
Barrie Van Den Berg, assistant coroner for Cornwall, said: “It is a well-known fact that people who have leg fractures and are elderly lie down a lot and suffer from bronchopneumonia.
“Without the fall he would not have died,” he added.
Mr Van Den Berg recorded that Mr hunt died as the result of an accident.
“My sympathies go out to the family,” he added.
The CQC carried out a follow-up inspection at Clinton House on November 26 2013.
The report, published last week, states the home had made improvements following the previous inspection.
“We previously inspected this Essential Standard of Quality and Safety in August 2013. The commission issued a compliance action as breaches of the regulation were identified,” the report said.
“Following our inspection, the provider submitted an action plan to the Commission to demonstrate how they would rectify the concerns which had been raised.
“As part of the review of this outcome area we assessed the areas of concerns which were previously identified to ensure the provider was now compliant. We found some improvements had been made.”