A CORONER has demanded to see a documentary trail of evidence that wholesale changes have been made at a nursing home since a dementia resident scalded herself with cup of tea suffering burns which contributed to her death.

An agency care worker, not aware of frail 95-year-old Kathleen Bland's special needs, left a double-handed beaker of tea on a table tray in front of her as she lay flat in bed at Troutbeck Nursing Home in Crossbeck Road, Ilkley, an inquest in Bradford yesterday.

Mrs Bland, who needed round-the-clock care, accidentally spilled the hot drink on her arm and thigh suffering superficial but painful burns shortly after the afternoon tea round on March 9 this year but the full extent of her injuries were not discovered until the night shift took over.

The hearing was told how day shift staff nurse Denise-Williams-Brown had been alerted to Mrs Bland's arm and applied Sudocrem, a practice not favoured by a nursing colleague or the NHS, but failed to check the rest of her body for burns.

Although she looked in one more time on Mrs Bland before catching her bus home, filling in an incident report had slipped her mind. Neither did she handover details of the incident in person to the staff nurse taking over from her, the inquest was told.

Care workers later alerted staff nurse Lisa Payne to the burn which had progressed into a large blister on Mrs Bland's arm and also uncovered the burn on her thigh.

An on-call doctor did not arrive until almost two hours later and then he called district nurses, who took another two hours to attend before they decided she needed to go to A&E at Airedale Hospital where she was kept in for three days and treated for dehydration and first degree burns before being discharged back to Troutbeck where she died ten days later.

Although pathologist Dr James Garvican said Mrs Bland had died from old age, Coroner Martin Fleming, recording a narrative verdict, said the burns had played a part in her death from natural causes.

It also emerged a significant checklist documenting Mrs Bland's care on the day of the incident had gone missing and could not be produced as evidence which Mr Fleming described as as a "serious matter".

"It was one of the most important documents. We don't have access to the notes so it's impossible to say with certainty who was and wasn't looking after her that day," he said.

The home's manager Janet Riding told the inquest there had been a major overhaul in way of changes, including care plans, handovers, note-taking and note-keeping, first aid training for all staff, supervised tea-trolleys, and a recruitment drive to employ permanent staff rather than use agencies.

But Mr Fleming said he would still be seeking more reassurances and will also ask the home to consider looking for an alternative to the beaker that spills if turned upside down.

He said: "I want to see things are being done. I would like something from the nursing home, a documentary trail, to see what policies relevant to this inquest are now in place."