Neglecton the part of a care home owner contributed to the death of one of the elderly residents, a coroner has ruled.

The judgment came after an inquest heard that Maureen Parry, owner and manager of the Halewood Residential Home in Llannerch Road West, Rhos-on-Sea, failed to seek medical help for 80-year-old Gloria Forrester despite 19 references in the home’s records to her having a pressure sore.

Mrs Forrester, who had been living at the home for five years, died at Glan Clwyd Hospital on August 5, 2016, two weeks after being admitted with a Grade 4 sore – the worst grade possible – on her bottom. The cause of death was respiratory failure stemming from the sepsis.

Mrs Parry told the inquest in Ruthin that the sore was not there two days earlier, but consultant geriatrician Dr Gerallt Owen said it was the worst he had ever seen and it could have started as early as April, when a “redness” was recorded.

Nicola Jones, assistant coroner for North Wales East and Central, recorded a narrative conclusion recording the simple facts of Mrs Forrester’s death but adding: “It was contributed to by neglect in not seeking medical attention for the pressure sore in the appropriate manner.”

Members of staff at the home told the inquest that when they drew Mrs Parry’s attention to the sore, which sometimes bled, she was reluctant to call a nurse or doctor.

But Mrs Parry, who had owned the home – now closed – for 31 years, said she had never refused to seek medical attention. She accepted, however, that she had no medical training and nor did any member of staff.

The inquest heard that an investigation by the Care and Social Services Inspectorate for Wales highlighted several failings in the running of the home, some of which had been flagged up previously.

They included poor record-keeping, inadequate training for staff, failure to carry out an assessment of needs on admission, lack of a care plan and resistance to seek medical advice and support.

Greer Milner, who carried out the inspection, said there real concerns about Mrs Parry’s competence and fitness to be manager.

“She was kind and compassionate but I had concerns about her understanding of what we were asking,” she said.

Following Mrs Forrester’s death a Protection of Vulnerable Adults (POVA) investigation was also launched, involving the Health Board, police and Conwy County Borough social services.

Catherine McKenzie, who headed the inquiry, said similar concerns were raised and an action plan introduced to protect the home’s other residents.

“On the balance of probabilities there had been an incident of neglect,” she said.

One of the recommendations was that someone on each shift should have the authority to contact a nurse or doctor, as staff had previously been told that only Mrs Parry could do so.

The inquest was told that Mrs Forrester’s daughter Sarah Williams contacted the community nurse after seeing the extent of the sore, which was giving off a strong odour. The nurse arranged for her to be taken immediately to hospital, but her condition deteriorated.

After the inquest Mrs Williams declined to comment.