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An investigation into a Coleraine care home has established that a resident's dentures were lodged in her throat for up to 24 hours before being detected.

A found "serious failings in her care" at The Cottage Care �鶹Լ��.

The woman also suffered a fractured leg while being moved by staff.

Conway Group Healthcare, which owns the home, apologised to the woman's family.

The resident's daughter complained to the ombudsman about the incidents.

The report found the home's failings in the care and treatment of the resident were preventable, and that the incidents may well have contributed to the shortening of her life.

The investigation found not enough care was taken while the resident was being helped to move from her bed to her chair.

During the manoeuvre the woman's foot became caught in the bedrail.

Despite the woman indicating she was in pain, staff continued with the move.

After the resident was in the chair, staff checked for injury, however this was not carried out properly and resulted in a full day's delay in the fracture being identified.

The ombudsman found that the incident with the woman's dentures was due to there being no oral health care plan as well as a failure to have a clear oral health care policy.

The resident had experienced swallowing and breathing difficulties, and the report criticised the home for not recognising sooner the possibility that this could be related to her dentures having gone missing.

However the investigation found that the Nursing �鶹Լ�� acted correctly in having an "appropriate moving and handling risk assessment" in place for the resident during the moving and handling Incident.

It found too that following both the moving and handling incident and the dentures incident, the home acted appropriately in relation to the implementation of adult safeguarding procedures.

'Trauma and distress'

Ombudsman Margaret Kelly said: "It is clear that the resident's daughter and her two brothers were devoted to their mother and very much involved in decisions regarding her care.

"The trauma and distress of losing her in the circumstances reflected in this report was evident in their correspondence to the home and to my office.

"I understand that this report will have made distressing reading and I recognise the emotional impact on a family in bringing a complaint of this nature forward.

"It is a testament to the love and devotion they had for their mother that they want to ensure no other family suffers a similar experience."

As well as recommending the apology, the ombudsman also asked the home to carry out staff training and service improvements in oral hygiene, and in the moving and handling of elderly residents.

Its recommendations were accepted by Conway Group Healthcare.