RETIRED machinist Arthur Horrod was found with bed sores as big as a woman's hand before he died a year ago.

Pathologists and doctors who examined 76-year-old Mr Horrod said he had the worst bed sores they had ever seen.

The jury at the four-day inquest into his death was told by Calne GP Dr Elizabeth Taudevin that she found a bed sore on his back the size of her hand.

Mr Horrod, who was described as a big man who had movement problems, died on November 6 last year at Chippenham Community Hospital.

He had been a resident at the Dunstan House Nursing Home in Calne and had been admitted to Bath's Royal United Hospital on September 1 after being examined by consultants at Chippenham Hospital.

Jurors at the coroners' court sitting in Chippenham on Monday took just over an hour to return a verdict. The jury foreman said: "Mr Horrod died from natural causes and the cause of death was contributed to by neglect."

The nursing home is owned by John and Margaret O'Dea who were in court to hear the verdict.

It was said during the inquest that an air mattress should have been provided for Mr Horrod, but wasn't.

In summing up, coroner David Masters said pathologists and doctors examining Mr Horrod, who had moved from Winter's Court, Corsham, said he had the worst bedsores they had ever seen.

"Dr Elizabeth Taudevin, GP at the Elm Grove Surgery, in Calne, has told you she was shocked and horrified when she examined Mr Horrod at the nursing home on August 31 2000," said Mr Masters. "They were the worst bed sores she had seen."

He said Dr Taudevin advised the nursing home that an air mattress would relieve the pressure points and help prevent bedsores. The court heard that that no air mattress was provided.

Mr Masters said Dr Taudevin had told the court she found a sore on Mr Horrod's back the size of her hand.

She had visited him several times at the home and had referred him to the urology unit at the Royal United Hospital after visiting him on August 16. Mr Masters said she had been surprised when she was called back to examine him again on August 31.

Mr Horrod was admitted to hospital in Bath and underwent surgery for the sores, which were located on his back, hip and near his groin.

He was referred back to Chippenham Hospital but died in November.

Pathologist Dr Suzanne Armstrong performed a post mortem examination on Mr Horrod at Swindon's Princess Margaret Hospital and discovered a sore on his left hip 16cm in length, 10cm wide and 4cm deep. On his back the pathologist found a sore 15cm long by 11cm wide and 2cm deep.

She put cause of death down to bronchial pneumonia due to movement problems, heart disease and pressure points, which are bedsores.

Home Office pathologist Dr Huw White, who carried out a second post mortem examination, said in his opinion the sores would have taken two months to develop.

In summing up, Mr Masters said that Mr Horrod was a large man who had suffered from incontinence, and was a difficult patient who had movement problems.

He said Dunstan House had called in a succession of experts to examine Mr Horrod prior to his admission to the Bath hospital.

Tissue viability nurse Gillian Wicks visited Mr Horrod on August 9 because he was suffering from itching.

She returned on September 1 and Mr Masters said: "The sore on his back was the size of a 50p piece."

The court heard that Mr Horrod had been referred to Goatacre Nursing Home, also owned by Mr and Mrs O'Dea, after suffering a stroke in 1999.

He stayed for three weeks before returning home but was readmitted, this time to Dunstan House.

He said in July last year John Horrod, Mr Horrod's son, visited his father at the home and saw a red mark near his hip. This was reported to Mr Horrod's nurse, Michael Nutland.

On July 23 2000 the court heard that Mr Nutland drew up a care plan for Mr Horrod. The care plan was not updated.

Wiltshire Health Authority published an interim report on the standard of care at Dunstan House after being informed of the case in October last year.

Amanda Noble, a registration and inspection officer for the authority, said adequate records of treatment given to Mr Horrod were not kept.

She said she had since returned and standards at the home had improved.

She said the home was short of one care assistant on 14 shifts between August 5 and 28 last year.

Mr Masters said the court had heard it could accommodate 40 residents and had 22 at the time Mr Horrod was there.

Ms Noble said Mr Nutland was also unqualified for the role of running a shift, which he held at the home. She said he had since become qualified.

The jury foreman said in returning the verdict: "We have found the care plan and daily records were insufficient to keep medical staff informed and there was not good liaison between nursing staff and GPs.

"Mr Horrod's pressure sores were not identified for a period of time and once it was established that he was at higher risk, treatment was inadequate and in some cases inappropriate, in particular the provision of an air mattress."

DS Nicholas Shorten, of Chippenham police, said six staff at the care home had been interviewed after a police investigation was launched on behalf of the Wiltshire coroner following Mr Horrod's death.

The Crown Prosecution Service has taken no further action.

Mr Masters told the inquest Mr O'Dea was responsible for the administration of the two homes and visited Dunstan House once or twice a week.

He said different types of beds were available at Dunstan House and it had an air mattress, but one was not available for Mr Horrod.

Afterwards, John Horrod, who lives in Calne, said he was satisfied and relieved at the jury's decision. "The truth has come out," said Mr Horrod. "It makes things a little bit better but it will never bring my father back."

How the homes are regulated

THE inspection and registration office of Wiltshire Health Authority is responsible for registering care homes in the county.

From April next year the responsibility will be taken on by the National Care Standards Commission and applicants will apply on a national basis.

Anyone wishing to open a care or residential home at the present time has to apply for an application form to Wiltshire Health Authority.

When the application is returned, references have to be included and if the authority is satisfied the application is genuine, police checks are carried out and references checked, among many other factors.

"It's a very rigorous and comprehensive process," a health authority spokeswoman said.

She said personal checks are always carried out on the proprietor, his or her agent and any other relevant people involved in the application.

Once checks have been carried out, a consultation process takes place.

The applicant is then called in for an interview.

The care home can be of two types.

If the application refers to general care, an interview would take place between the applicant and two registration officers.

If it is catering for specific care, the health authority consults with the Social Services.

Once the interview has been completed it should take a small amount of time for the applicant to receive his or her registration.