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Neglect contributed to the death of a musician in a care home, a coroner has concluded.
Paul Chin died of sepsis due to a catheter complication in his room at the Woodchurch House Care Home in November 2015.
The 47-year-old's death came after a long list of complaints from his family and partner regarding care at the Ashford-based facility, which that year saw 34 deaths occur.
Assistant coroner Sonia Hayes presided over the three-week inquest into his death, which took place at County Hall in Maidstone.
Mr Chin didn’t leave his room once in the 10 months he’d been at the home due to a lack of bespoke equipment.
Ms Hayes said: “He was erroneously noted as bedbound and that catheterisation was necessary. Catheters carry a risk of infection.
“This more than minimally contributed to his death.
“His care plan on October 29, 2014 states he could stand. He had no trouble independently sitting out on the side of his bed.
“I find Paul wasn't bedbound by reason of his medical ailments.
“The recommendations for equipment to assist in his rehabilitation had been made, but none had been provided up to the time of his death.
"Delays were significant and Paul was confined to his room for 10 months.
“The issues around complaints regarding his catheter were raised on a number of occasions by his partner and family.
“There were no risk assessments in place, and evidence that training hadn’t been given.”
Regarding the day of his death, November 26, the County Hall court heard how a doctor’s recommendations weren’t carried out or recorded properly.
Ms Hayes said: “These were simple matters - basic medical checks and observations that weren’t completed, decisions that weren’t recorded.
“At 10.30pm, it’s highly unlikely that vital signs would have been normal as he was already displaying signs of sepsis.”
It was also found that the day-long stomach complaints of Mr Chin weren’t communicated to the doctor who visited.
The medical cause of his death at 3.50am on November 26, 2015, were identified as “sepsis caused by acute on chronic ascending pyelonephritis due to an indwelling urinary catheter and past meningeal tuberculosis and limited mobility”.
Ms Hayes concluded: “This was a gross failure to conduct simple basic checks in a dependent person to summon timely medical assistance that would have prolonged his life. Neglect contributed to his death.”
Ms Hayes will decide whether a Regulation 28 order - a report to a person, organisation, local authority or government department or agency noting the details of the case - will be issued.
This would force an assurance that actions have been taken relating to to prevent further deaths from occurring.
Following the inquest, Paul’s family said: “Paul’s unnecessary and avoidable death has left us both heartbroken and angry.
“We believe the way Paul was treated in the 10 months he was at Woodchurch House care home was inhumane.
"Fighting for better treatment for Paul while he was alive was incredibly difficult because the care home and other agencies responsible for his care continually shifted responsibility to each other" - Paul Chin's family
“Fighting for better treatment for Paul while he was alive was incredibly difficult because the care home and other agencies responsible for his care continually shifted responsibility to each other.
“The blame-shifting continued following Paul’s death and during the inquest.”
A spokeswoman for the Woodchurch House care home said of the outcome: “The health, safety and wellbeing of our residents, are, and always have been, our top priorities.
“We have noted the coroner’s findings and will be considering this further.
“Different systems and processes are now in place at the home.
“We wish to once again convey our condolences to Mr Chin’s partner and family.”
