CONCERNS were raised over the "neglect" of a nursing home resident who had been found with "rotting flesh" leaking from his plaster cast, an inquest heard.
Retired master baker Reginald Stone, aged 96, died at St Martin's House in Camborne on October 8, 2011.
The Welsh-born widower, who suffered from dementia, a severe heart condition and diabetes, fell in his room at another care home eight months earlier, fracturing his right calf bone.
When he was discharged from the Royal Cornwall Hospital at Truro on March 25, Mr Stone was relocated to the Camborne nursing home.
On May 20, South Western Ambulance Service staff raised a safeguarding alert after a crew that arrived to transport Mr Stone back to the hospital became concerned for his wellbeing.
He was said to be found in a lot of pain, the smell in his room described as "unbearable" and his plaster cast "leaking goo".
An investigation revealed two severe pressure sores around his knee.
The concerns were investigated by PC Alison Gessey, a safeguarding officer based at Pool police station.
She found no evidence of wrongdoing by staff members and no prosecution was pursued, the inquest at Truro heard.
A report from the officer read: "Concerns about neglect by St Martin's House were raised after ambulance staff found rotting flesh coming out of his plaster, which had not been changed for 14 weeks."
A consultant pathologist, Joe Matthew, from the Royal Cornwall Hospital, expressed his surprise that "there was this smell and nobody did anything about it", adding: "If you smell something you have to try to figure out what's happening."
Mr Stone's GP, Timothy Keech, from Phoenix Surgery in Camborne, admitted it was "unfortunate" the smell had not been brought to attention but said pressure sores can develop relatively quickly.
He said: "He had been in hospital two weeks earlier so I would have expected the hospital to notice if goo was appearing.
"There was no negligence at the care home and they were treating him well."
Recording a verdict of death by natural causes Cornwall Coroner Emma Carlyon confirmed there was no evidence of neglect and that it was unfortunate the ulcers had not been identified earlier. Douglas Webb, the chief executive at Cornwall Care, which owns St Martin's House, said he was satisfied "everything was handled properly".