Oaklands Rest Home in Marchwood was at the centre of a police probe after three residents died in three months

Winchester Coroner’s Court heard how three people died at Oaklands Rest Home in Veals Close, Marchwood between September 2014 and December that year, prompting the investigation.

The inquests heard that the police decided there was not sufficient evidence to recommend prosecution.

One of the deaths was that of Pamela Carey, 77, who had only been at the home for two days when she choked on a sausage roll and suffered a heart attack on September 3, 2014. She died three days later at Southampton General Hospital.

The inquest heard how Mrs Carey suffered from Alzheimer’s, diagnosed in 2011.

She had previously stayed at the care home for two weeks in April, and had gone in to stay two weeks in September.

Speaking at the inquest, her husband Raymond Carey explained he told staff at the care home before she arrived in September, that was at risk of choking due to loose dentures and needed supervision when eating.

The court heard how Mr Carey visited on August 25 to fill in a pre-assessment form with a staff member, which would be what Mrs Carey’s care management plan would be based on.

He came back to the home on September 1, and raised concerns about his wife’s need to be supervised while eating.

The pre-assessment care forms however, showed no note of this, but the updated September form did indicate she had dentures, which were not there in April.

Giving evidence, Ashleigh Rutherford, a senior carer at the home, explained she had gone through the pre assessment form with Mr Carey and would have noted supervised eating in the form.

The hearing heard a statement from carer Casey Barnes who stated she left Mrs Carey after making her a sausage roll, and on her return Mrs Carey was unresponsive.

Ms Barnes said she left her for two minutes, the coroner and her employer Amish Patel disputed this and said it was more likely to be five to ten minutes.

The inquest also heard how Ms Barnes believed Mrs Carey suffered a heart attack which was passed on to ambulance staff, who asked her to perform CPR before they arrived within 13 minutes.

Home office pathologist Dr Russell Delaney said the cause of death was hypoxic ischemic brain injury due to prolonged cardiac arrest due to choking.

He said although it would be helpful had Mrs Carey been supervised when eating, it may not have prevented her death as dementia sufferers are prone to choking, but it may have sped up the process of medical attention arriving.

The detective sergeant at the time Naomi Melish told the hearing that police investigated the deaths in 2014, they bought the case forward to the Crown Prosecution Service and later the serious crime review, but there was not enough evidence to continue proceedings.

Coroner Simon Burge recorded a narrative verdict and did not blame staff members at the care home for the death, although he said there were inconsistencies in Ms Barnes evidence.

Mr Burge said: “Even if she had been helped to eat and had a member of staff present that would have not necessarily lead to an improved outcome.”

The second inquest on Wednesday was into the death of 83-year-old Irene Price, who suffered a fatal brain injury after a fall on December 6 2014.

The court heard she suffered dementia of a type strongly associated with falls.

She walked around independently with a crutch but had fallen “loads of times” and needed supervision on stairs, care assistant Alecia Martin told the hearing.

"She's the type of person who, sometimes, you can't tell her what to do. She just does what she wants,” she said.

The carer told how she took Ms Price to a 'quiet room' after an altercation with another resident.

Ms Martin walked around the corner to make a cup of tea and heard a loud bang, she said. Ms Price was found on her back at the foot of the stairs.

She was rushed to Southampton General Hospital, where doctors found she had suffered a serious brain injury.

No direct medical intervention was made and she died on December 15.

Pathologist Dr Amanda Jeffery said: "It can be that falls are almost inevitable, particularly in someone that's independent and wants to get about."

Ms Price lived on the ground floor and had to be supervised when using stairs, Ms Martin said.

Assistant coroner Simon Burge recorded a verdict of accidental death.

He said: "In relation to this particular death, tragic and unexpected though it was, I can’t find any suggestion or evidence that Irene was not cared for appropriately or that there’s any foul play or other relevant complicating factor that we need to take into account.”

The third Oaklands death was that of 94-year-old Joan Gould who died on September 27.

Officers probed her death after allegations of mistreatment.

More than a year after her death, an inquest found Mrs Gould died of chronic heart failure.

The Winchester hearing heard how Mrs Gould suffered dementia, chronic heart swelling and hypertension.

She was rushed to hospital in September 2014 after a "complete vacancy of mind" lasting 40 minutes, the inquest heard.

She was later discharged to Oaklands, but the inquest heard she was removed days later by family who feared she was being mistreated. The details of their allegations were not disclosed to the hearing.

Relatives sent Mrs Gould back to Southampton General Hospital, where she died the next day on September 27.

In a report read to the hearing, Home Office pathologist Dr Basil Purdue found she was killed by chronic congestive heart failure and hypertensive heart disease.

"There were no features to suggest that Joan Gould had been subjected to neglect or ill treatment of any kind, and her body appeared well cared-for," he said.

Senior central Hampshire coroner Grahame Short recorded a verdict of natural causes.

Dr Purdue added that the mental episode was caused by "gradual" brain damage, linked to her heart swelling but unrelated to the death.

Relatives described Mrs Gould as a strong character who liked to laugh who would take "any excuse to put a party on".

Oaklands declined to comment, but on its website it says: “Our staff are trained to NVQ Level 2, 3 and 4 and in accordance with the necessary regulations offer experienced care and support to our residents.

"Stimulation therapy is provided on a daily basis for those who wish to participate, including arts and crafts, one on one activity sessions, keep fit and board games.

“We offer only the best standards of care and comfort to our residents and we encourage friends and family to visit regularly and provide feedback to us about the service we provide.”