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Joan Chapman, 96, died of hypothermia after leaving her care home through an unlocked door; inquest found major failings.
Joan Chapman, 96, died of hypothermia after leaving Coombe End Court Care Home in Marlborough, through an unlocked door in cold temperatures.
An inquest found the care home, run by the Order of St John Care Trust, had significant failings including not locking doors, neglecting alarms, and poor staff training.
The trust has since introduced electronic checks, improved training, and new security measures.
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Joan Chapman, de 96 años, murió de hipotermia después de salir de su hogar de cuidados a través de una puerta sin llave; la investigación encontró fallas importantes.