An elderly stroke victim who died after suffering malnourishment and pressure sores experienced “significant failures” in basic care at a nursing home, an inquest has been told.

Bed or chair-bound Dorothea Hale, 75, died in hospital weeks after being admitted from the Grosvenor House nursing home in Abertillery, Monmouthshire.

On Wednesday, coroner Geraint Williams highlighted a number of failures by care staff during the mother-of-two’s four months at the home between July and November 2006.

But he said a lack of evidence that better care would have prolonged her life meant he could not record that her death in January 2007 was contributed to by neglect.

The four-week inquest into Mrs Hale’s death, held in Newport, was blighted by a substantial number of “critically important” missing records and documents from the home, as well as the refusal of some ex-staff to give evidence.

Mr Williams said he was not given an explanation for the missing records, and said in the case of the development of pressure sores on Mrs Hale’s body meant he was unable to say “where the ultimate responsibility for the identified failures in Mrs Hale’s care actually lies”.

The grandmother had a peg tube feeding system fitted before moving into Grosvenor House as she had difficulty swallowing after suffering two strokes which left her paralysed down her left side and needing full-time nursing care.

But after moving into the home she was put on an oral feeding regime despite her sometimes refusing to receive any food, leading to her becoming malnourished and possibly dehydrated.

Mr Williams said a failure by staff to seek a referral from clinicians to reintroduce Mrs Hale to peg feeding “amounted to a significant failure in the provision of basic medical care”.

Dr Antony Hawthorne told the hearing that Mrs Hale’s eventual reintroduction to peg feeding on November 1 triggered “refeeding syndrome”, a serious and potentially fatal metabolic disturbance.

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Mr Williams said “significant” pressure damage was found on Mrs Hale’s body after she was admitted to hospital on November 17 and had developed while she was at Grosvenor.

He said it was contributed to by a lack of nutrition, refeeding syndrome, and “inadequately relieved pressure” while sitting or lying down.

The coroner said there were “a number of significant failures to provide or procure for Mrs Hale the basic medical attention that she obviously needed”.

He said the failure escalate the treatment of her pressure damage “was a gross failure to provide or procure basic medical care”.

But the evidence available did not allow him to say that earlier escalation “might have saved or prolonged Mrs Hale’s life”.

“Therefore I conclude that as a matter of law I may not find that Mrs Hale’s death was contributed to by neglect,” he said.

Two staff members were investigated by the Nursing and Midwifery Council in connection with Mrs Hale’s death and were both found unfit to practice and struck off the NMC register, Mr Williams said.

Mrs Hale’s cause of death was given as a combination of her stroke, pressure ulceration, lack of adequate nutrition and refeeding syndrome, and other blood clot complications as well as a rupture of chordae tendineae in her heart.

Mr Williams recorded a narrative conclusion, and said he did not need to issue a prevention of future deaths report because after 15 years “the legislation, regulations and equally importantly the philosophy and practice of state agencies has changed markedly”.

Ms Hale’s death featured in Operation Jasmine – a police investigation into neglect of elderly residents at several care homes in South Wales.

The inquiry lasted nearly a decade and cost over £11 million with detectives looking at 63 deaths.

Earlier this year, a coroner found the deaths of five residents at the Brithdir nursing home in New Tredegar, South Wales, which featured in Operation Jasmine, were contributed to by neglect.