A care home has been criticised by the coroner after a resident died.
84-year-old Victor Costello was a resident at Primrose Court Nursing Home in Stockton, when he was taken to hospital in February 2020.
Mr Costello died from pneumonia six days later.
Now, Jo Wharton, Assistant Coroner for Teesside & Hartlepool, has raised "concerns" about his care in the hospital and filed a Prevention of Future Deaths report.
This means that a report has been drawn up, and the chief coroner is notified of the concerns. The care home management are also required to implement a plan to prevent deaths in the future, and are under a duty to respond by May 9.
The assistant coroner wrote in her report: "During the course of the inquest [into Mr Costello's death], the evidence revealed matters giving rise to concern.
"In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you."
In the run-up to his death, Mr Costello nil by mouth and fed with a feeding tube on his doctor's orders.
But his family raised concerns that Mr Costello had told them he had been drinking water from the taps in his bathroom.
Evidence was given at the inquest by the manger at Primrose Court nursing home that such concerns were communicated to all staff.
However, further evidence showed that such communication was "not effective."
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This was because the nurse in charge and the two care assistants who were on duty on the morning Mr Costello was taken to hospital, all denied being aware of such concerns.
The coroner added: "In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action."
The report has been sent to the Care Quality Commission, the chief coroner, the nursing home's leadership team, and Mr Costello's family.
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