A FORMER Japanese prisoner of war was found dead outside a Westbury care home after one of the coldest nights of last year, an inquest was told yesterday.

Frederick John Baxter, 97, known as John, spent only 16 days at the Greengates care home in Redlands Lane before being found by staff at 5.50am on Monday, February 13 2017.

The resumed inquest at Salisbury into his death heard he died overnight on the Sunday/Monday just six days short of his 98th birthday after wandering outside in temperatures as low as three degrees centigrade.

The retired heating and plumbing engineer, formerly of The Croft, Trowbridge, had been left a widower after his wife Lilian died from cancer in 1982.

His two sons Michael and John Baxter, and daughter Mrs Vanessa Heard, moved their father to Greengates on January 27 2017 after he was treated at the Royal United Hospital in Bath for a urinary tract infection.

Mr Baxter was found laying naked from the waist down in a narrow alleyway between two courtyards after staff mounted a frantic search to find him when they realised he had not slept in his bed on the first floor.

The inquest was told that on Sunday, February 12 Mrs Heard had visited him between 10.30am and 12 noon and John Baxter between 5pm and 6.30pm that evening.

Mr Baxter was given eyedrops medication at 7pm by staff who then failed to check overnight whether he was safely tucked up in bed.

The two care home staff on duty – team leader Philip Lane and care assistant Lianne Parsons – began the search early the next morning after going into his room to wake him up and finding he was not there.

When they found him, they called care home manager Sarah Winchester, instead of immediately dialling 999. PC Cathy Byers and PC Neil Le’maire were called out to the home at 6.20am by Ms Winchester.

PC Cathy Byers, based in Warminster, said she found just two staff – Mr Lane and Ms Parsons - looking after 31 residents. A third member of staff who should have been on duty had called in sick and had not been replaced.

The two constables found Mr Baxter in the alleyway covered by a white sheet. He was wearing only a shirt and pullover, which was covered with grass and fragments from a lavender shrub.

In the courtyard nearby, they found a broken plant pot and Mr Baxter’s boxer shorts, socks and slippers.

He had taken off the jogging bottoms he had been wearing and Ms Winchester had asked staff to take them to the laundry to be washed.

Forensic pathologist Dr Amanda Jeffrey told the inquest she could not say for certain what had caused Mr Baxter’s death but his heart condition and hypothermia could both have been contributory factors.

“On the balance of probabilities, I can’t give more weight to one than the other,” she said.

Her post mortem examination showed he was suffering from hardening of the arteries to his heart, and he had bruising to his left temple, knuckles, the tops of his feet and buttocks, as well as grazes on his hips.

It was suggested that Mr Baxter, who was living with dementia, had wandered outside in a confused state and had fallen. From the bruising and grazes, it appeared he had tried to crawl along the path.

The inquest was told he could have lain there for several hours as the staff on duty had not known he was missing and had not seen him go outside through an unlocked door.

Both John Baxter and Mrs Heard said they noticed their father was not wearing his prescription glasses during their visits but cheap ones the care home staff had found for him.

Mr Baxter said his father would not have been able to see properly without his prescription glasses, as he had a detached retina in one eye and a cataract in the other.

Although mobile, his father walked with a stick and was using two hearing aids. However, had become more confused following his illness and was prone to wandering.

Mr Baxter said his father was “extremely agitated” about the jogging bottoms he was wearing when he saw him, because he was the kind of man who usually wore smart trousers.

Assistant Coroner, Nicholas Rheinberg, warned the care home staff giving evidence not to incriminate themselves because of the possibility of them facing further criminal or civil legal proceedings.

The care home staff on duty and managers were all interviewed by Detective Sergeant Adrian Bray and Detective Constable Kerry Foster at Melksham Police Station.

They included Sarah Winchester, who was interviewed under caution for offences of ill treatment and wilful neglect, as well as Mr Lane and Ms Parsons.

All three face the possibility of formal action by the Care Quality Commission, which gave Greengates an ‘Outstanding’ rating in September 2016.

A third member of staff, Lorna Connor, had volunteered to come into work at 8pm that evening to do domestic chores and the laundry even though she was not rostered to do so.

She said she went home just after 11pm after completing her chores. She was not trained to give medication to residents.

Following Mr Baxter’s death, Mr Lane and Ms Parsons were immediately suspended. Sarah Winchester left the care home in March last year and is now an office worker.

The Baxter family told the inquest they had chosen Greengates because of its CQC rating and because it specialised in caring for residents with dementia.

Mrs Heard said: “That was the only reason why we put him in there. We felt that it was a place where he could die with dignity. Unfortunately, that did not happen.”

The inquest was told that none of the staff knew Mr Baxter was missing until his body was found the next morning.

He had a pressure mat in his room with a sensor alarm system to alert staff if he got out of bed. However, the mat was not plugged in after being re-set on Sunday and the alarm never went off.

Mr Lane and Ms Parsons also admitted that ‘walk-arounds’ the care home after the 8pm handover and hourly checks on residents did not always take place.

In addition, Mr Lane admitted he sometimes slept while on duty and on other occasions watched TV or films as “background” while performing tasks.

He had failed to check on Mr Baxter at 10pm to give him his eye drops because he had “forgotten” to do so after dealing with problems involving residents on the ground floor.

Staff also failed to check Mr Baxter’s room when doing their 2am rounds to “turn” residents who needed to be moved to relieve pressure sores.

Ms Winchester said she did not always double-check the hourly check records submitted by staff, only the care plans and daily record sheets as legally required by the CQC.

She said that several days before his death, in an entry dated February 7, 2017, Mr Baxter had asked for the hourly checks at night-time to be stopped because they disturbed his sleep.

She admitted that the Baxter family had not been informed about this, nor about a change in Mr Baxter’s medication for his health conditions.

Ms Winchester said she had frequently resisted attempts by the Greengates care home owner, Chong Siam Yeoh, to reduce the number of staff on duty.

The inquest was told the home usually had six staff on duty in the morning, five in the afternoon and three in the evening. Ms Winchester said Mr Yeoh refused to allow her to employ agency staff because the CQC did not like it.

On February 12, a member of the afternoon staff had called in sick and another left early at 4.30pm because her dog was being put to sleep.

In the evening, the third member of staff who should have been on duty had called in sick and no replacement had been found.

Mr Lane said he decided to just “get on with it” instead of informing Ms Winchester and the home’s deputy manager, Lisa Coxon-Tenty, that they were short staffed.

Ms Winchester said that if she had known, she would have tried to find cover. She often covered 12-hour shifts herself and had done so the previous Saturday.

She told the inquest she was in a state of shock after learning of Mr Baxter’s death and “could not recollect” asking staff to take his jogging bottoms to the laundry to be washed.

The inquest was told that while “extremely saddened” by Mr Baxter’s tragic death, she did not feel she was responsible for it.

Ms Winchester declined to attend the first police interview and provided a written statement for the second. The inquest was told she was asked a “large number” of questions, to which her response was mostly “no comment”.

Greengates care home closed on September 25 last year following a two-day Care Quality Commission inspection on July 26 and 27.

The inquest will resume today with evidence from three key members of the management team, including the care home owner, Mr Yeoh.