A coroner’s investigation has found a care home took two days to call emergency services for a resident who later died in hospital.

The Prevention of future deaths report was published by coroner Jacqueline Lake following the death of 82-year-old Geoffrey Whatling, a former resident of Athena Care Homes’ Amberley Care Home in King’s Lynn.

The investigation found the care home failed to call 999 on 8 April, 2023 despite his health deteriorating to the level where emergency services should have been contacted.

Staff instead called 111 and carried out further observations until Mr Whatling’s health declined again on 10 April when emergency services were finally alerted and he was taken to Queen Elizabeth Hospital.

Mr Whatling died at hospital on 26 April. The medical cause of death was infective exacerbation of chronic obstructive pulmonary disease, frailty and old age.

The coroner’s investigation found a number of areas of concern, including: Mr Whatling not eating and drinking very much and his food and fluid chart not being fully completed; evidence suggesting the 111 call taker not being made aware he had reached the level required for emergency services intervention; observations not being taken hourly as required and being recorded on a piece of paper and not logged in care records; and the manager only becoming aware of gaps in records following concerns raised by the family.

Amberley Care Home, which was last month rated Inadequate by the CQC, has been given to until 22 December to respond to the report.

A spokesperson for the care home said: “The safety and well-being of our residents will always be our utmost priority.

“We are currently in the process of working transparently with the relevant authorities regarding this report. Our thoughts are with Mr Whatling’s family and friends at this sad time.”