The family of a pensioner who died weighing five stone at a care home have demanded an inquest into her death.
Kathleen Cole died of pneumonia, aged 77, after five years at Holmwood House, which has had eight allegations of abuse or neglect upheld in the last two years.
She struggled to eat unaided and her family claim staff would often leave her to go hungry as feeding her a meal could take up to an hour.
Kathleen – once a healthy size 12 to 14 – survived on a pureed diet and just a bowl of soup a day with half a slice of toast, her family claim.
When she was moved to a different home in her dying days, records at Holmwood claimed she weighed 7st 12lbs (50.3kg). But when carers at the new home weighed her it revealed her actual weight was just 5st 5lbs (34.1kg) – suggesting her weight was not being monitored.
Holmwood House, in Westbury-on-Trym, Bristol, has been the subject of 33 "safeguarding alerts" over the past five years.
The former dinner lady's daughter Annette Whiting believes her poor care contributed to her death and has recruited a law firm to push for an inquest.
Mrs Whiting, 54, of Sea Mills, Bristol, yesterday said: "My mum deserved to be treated with dignity and respect and I thought she was in the safest place possible at Holmwood House with people who were used to providing her specific care needs. I've been told the safeguarding team have nothing to answer for, but mistakes were made. You don't go from one care home to another five minutes away and catch pneumonia and you don't lose 15kg in weight in one month. It doesn't happen."
Mrs Cole was widowed at 37 after her husband John died in an industrial accident. She was left to look after her five children on her own. When they were older, Mrs Cole worked as a dinner lady.
The great grandmother "lived an active life" but was diagnosed with dementia aged 66. Towards the end of her life, her "complex needs" meant she was dependent on people to do everything for her.
She was admitted to Holmwood House in 2008 and Mrs Whiting says she repeatedly expressed concerns to staff.
"She was prescribed two drinks supplements a day and a high-protein, pureed diet," said Mrs Whiting. "Of an evening she'd have a bowl of soup, half a slice of bread and butter and a yoghurt. It would take one hour to feed her and there were days when no fluid was given to her. If mum didn't open her mouth they'd walk away. I saw my mother every night and would make my concerns known. Holmwood House didn't even realise she was coming to the end of her life. Holmwood said she was in good health – rubbish."
Lawyers have seen notes taken during an internal meeting after Mrs Cole's death which revealed issues with nutrition and hydration, manual handling, skin care and management and administration of medication. Staff at the care home also failed to manage a pressure sore and failed to diagnose pneumonia, it is claimed. She was also being treated by a care worker currently being investigated by the Nursing and Midwifery Council on abuse allegations.
Among Mrs Whiting's concerns are that her mother was given an enema which she says was unnecessary and left her mother distressed. The nurse was later found guilty of assault over the incident – a verdict later overturned on appeal. She resigned from Holmwood after being suspended. However, a council investigation upheld an allegation of abuse and the nurse remains under investigation by the NMC.
Mrs Cole had an assessment to change home on July 22 but her family claim there are no records of her having any medication from there until she left on the July 29. When she arrived at Westbury Nursing Home staff could not believe how light she was. Mrs Cole died at the home two weeks later, in August last year. A post mortem stated the cause of death as pneumonia.
Mrs Whiting added: "I owe it to my mum to get answers about her care and I believe an inquest is the only way."
Holmwood House is owned by Ghassan Al-Jibouri, can cater for up to 41 residents and describes itself as "a luxurious nursing home". However, last year it stopped admitting patients with nursing needs under what was described as a "voluntary" arrangement. It followed a risk assessment by the council and suspension of admissions between June and August last year.
Specialist law firm Irwin Mitchell has written to Maria Voisin, the Coroner for Avon, asking for an inquest into Mrs Cole's death. Jonathan Peacock, from Irwin Mitchell, said: "We've reviewed a number of investigations into the care Mrs Cole received and believe factors including inadequate training, qualifications, management and supervision need exploring further. We're calling on the coroner on behalf of Annette to hold an inquest into Mrs Cole's death."
Requests have been made to Holmwood House's lawyers for a comment.