The death of an 81-year-old man in a care home has prompted a coroner to raise concerns about a lack of training for staff.
Roland Stannard died following a stay at the Bupa-run Chilton Meadows Care Home, in Stowmarket.
Mr Stannard developed a sacral sore after being left on a commode chair overnight.
This developed into an infection, which led to his death.
An inquest into his death found that the lack of care given to him during this time amounted to neglect.
Following the inquest, senior coroner for Suffolk, Nigel Parsley, has issued a prevention of future deaths report raising concerns about the training available to staff at the home to deal with sores.
Mr Parsley acknowledged that some changes had been made to some aspects of staff training but raised concerns about others.
"Due to staff inexperience and lack of training, the equipment provided to reduce the further development of his sacral sore was either not utilised, or if utilised sometimes used incorrectly,” said Mr Parsley.
The inquest heard that a high-grade air alternating mattress was too high for someone of Mr Stannard’s weight and an automatic lateral turning system was unplugged.
This meant Mr Stannard did not receive the intended benefits of the treatment.
A district nurse was told that staff did not know how to operate the device.
“I am therefore concerned in relation to the provision of specialist equipment to any care home setting, in which the care home staff have insufficient knowledge and training on how to properly operate this specialist equipment,” said Mr Parsley.
In the report, Mr Parsley also raised concerns about assessments made to decide whether someone needs nursing care, rather than social care.
In addition, he questioned whether the need for certain types of medical equipment should necessitate this assessment.
Speaking after the coroner's original conclusion, Mr Stannard's daughter Ali Green said she was pleased the truth had come out.
"I can't bring my dad back but I can get justice for my dad," said Mrs Green.
"I just want to be sure I've done as much as I can do to make sure it doesn't happen to someone else and somebody else's family."
Linda Burrows, regional director for Chilton Meadows, said: “We are deeply sorry for the errors in Mr Stannard’s care and our thoughts are with his family.
“We have since made significant changes to prevent this happening again. These include further training for colleagues and increased staffing across the home. We’ve also appointed experienced unit managers to oversee changes who are having a positive impact across the home.”
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