A care home has been criticised for failing to call 999 quickly enough for a resident who later died in hospital.
Concerns have been raised over Amberley Hall Care Home in King's Lynn - which is rated inadequate by the Care Quality Commission - following the death of 82-year-old Geoffrey Whatling.
Mr Whatling died at the Queen Elizabeth Hospital earlier this year from infective exacerbation of chronic obstructive pulmonary disease.
A full inquest into his death is scheduled to take place next year, but ahead of this hearing senior coroner Jacqueline Lake has raised concerns about how the home responded to his illness.
In a report to prevent future deaths, Mrs Lake stated Mr Whatling's family had told the home that he was unwell on April 8.
Observations were carried out on him using a method called the national early warning score (NEWS2) system - which assessed whether emergency services should be called.
Mr Whatling's score was above the threshold requiring urgent emergency care, but the home called 111 instead of 999, not mentioning his NEWS2 score.
It was not until two days later, when his condition worsened, that emergency services were called and he was admitted to hospital, where he died on April 26.
In her report, Mrs Lake also raised concerns about gaps in Mr Whatling's care.
These included:
- Hourly observations not being taken on him
- Staff not ensuring he was eating and drinking well or completing his food and fluid chart
- Managers not being aware of gaps in his records when staff raised concerns
A spokesman for Athena Care Homes, which runs the home in Baldock Drive, said: "The safety and wellbeing 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."
