The carers of a 98-year-old woman were unable to spot the tell tale signs that she was dying.
Joan Richardson was living in supported accommodation when her health quickly deteriorated. In April, 2020, the "frail" woman's condition declined to the point where she needed more support with her personal care, was not eating enough for her needs and started to show signs of confusion.
An ambulance had first been called on April 23, 2020, by the warden of the complex, but the paramedics determined Joan did not need to go to hospital but needed help with her personal care. The following day the local authority determined she would need home care, with it being provided until a private care provider was able to take over on April 29.