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10 January 2013, 10:45 | Updated: 10 January 2013, 11:03
The grandson of a 100 year old who died as a result of failings in training at a Bedfordshire care home has called her death 'a disgrace'.
May Ward fell out of a body sling that her two carers were not trained to use.
The great-grandmother died of multiple skull fractures and a brain haemorrhage after falling out of the sling her two carers were using to hoist her into bed at Meppershall Care Home in August 2010.
The carers, who are originally from China and Bulgaria and have now left the country, had not been trained to use the new type of sling introduced to the home three months before and did not fasten the leg supports properly, a jury at Hatfield Coroner's Court found.
Ms Ward, a former London pub landlady, sustained multiple skull fractures, a broken right leg, a black eye, and other cuts and bruises at the Bedfordshire care home and had to wait at least an hour for an ambulance after her fall.
During the 40-minute delay between her fall being reported to the on-duty nurse and staff at the hospital calling 999, the carers put Ms Ward in bed and changed her clothes, which could have made her injuries worse, the inquest heard.
The former Royal Air Force cook was taken to Lister hospital in Stevenage but died the following day.
The incident was not properly reported to the authorities by staff at the hospital - a breach of regulations.
The care home manager at the time, Judith Eglen, told the inquest she sent a fax to the relevant agencies, but did not know if it arrived as the home's fax machine did not have a read receipt function.
The jury gave a verdict of accidental death but management or staff at the care home could now face criminal charges in relation to Ms Ward's death under health and safety legislation.
Concerns about moving and handling residents at the home had been raised as far back as November 2009 by watchdog the Care Quality Commission (CQC). The care home was given a zero, or "poor'' rating, by the CQC in December 2009, which was uprated to a one-star rating in May 2010, around three months before Ms Ward died. After a random inspection on 6 September 2010, eight days after Ms Ward's death, the CQC said the care home still fell short of standards.