During an inquest into the death of Norma Lockton, 90, assistant Nottinghamshire coroner Elizabeth Didcock identified “gross” failings in her care at Jubilee Court Nursing Home.
Great-grandmother-of-two Norma died of sepsis at Bassetlaw Hospital on March 4 last year.
The sepsis and cellulitis infection was caused by a wound behind her left knee - the result of pressure sores left untreated by staff at the home.
Norma’s daughter alerted workers to the awful injury while visiting in late February, however shockingly, it was another two days before emergency services were called to the care home.
By this time the pensioner was already showing signs of sepsis - her leg was clammy, swollen and red and her temperature was 38.9 degrees while she was hot to touch and her breathing was irregular.
Paramedics found a wound so deep that Norma’s tendons could be seen behind her left knee.
After being rushed to hospital she died a few days later of advanced cellulitis with systemic sepsis.
Norma had been a resident at Jubilee Court Nursing Home since September 2017 and despite suffering from dementia and blindness was fit and healthy until February last year.
As her mobility deteriorated the district nursing team diagnosed Norma with pressure sores - recommending specialist wound dressings were kept in place, regularly checked and washed four times a day to allow a full recovery.
However coroner Elizabeth Didcock was told how the care plan had been disregarded - Norma’s injuries were not checked every two hours nor were they washed and re-bandaged.
The coroner also found that had the care home picked up on the seriousness of Norma’s condition and called the emergency services sooner, on a balance of probabilities she would have survived.
During the December inquest Ms Didcock concluded the failures of care by Jubilee Court staff had a clear and direct causal link to Norma’s death.
The lack of two-hourly checks on Norma’s knees, four times daily washing and replacing of dressings, lack of recognition for Mrs Lockton’s deterioration and failure to call for medical assistance earlier amount to a “gross failure” to provide basic medical attention.
Norma's daughter Vicki Bass told how her family had been left “truly shocked” by her experience at Jubilee House.
She said: “Our mother was larger than life and deserved greater care and respect from the care home.
“While it's been hard to comprehend we’re pleased with the coroner's report and as a family can start to move forward."
Norma's son Mark Lockton, said: “It's incredibly hard to understand the lack of care my mother received and that she was in pain for her final months of life.
"More needs to be done to ensure elderly people receive the grace and care they deserve in their later years. My mother was a wonderful woman and deserved a lot more.”
Fern Wright, of Lime Solicitors, representing Norma’s family, said the coroner’s conclusion highlighted “the true extent of the neglect Norma suffered” and “the complete disregard by care home staff for her care plan”.
Jubilee Court Nursing Home has not responded to requests for comment.