STAFF shortages, low morale and incompetence at Norlands Park nursing home led to the state of neglect which killed Honora Derham, it was revealed.

And at the centre of the maelstrom was matron Jane Yelland, the kingpin of the whole operation, a woman who held the future of the home's 30-plus patients in her hands.

However, the inquest into Mrs Derham's death revealed Yelland was a woman who found it almost impossible to juggle the twin demands of nursing care and the mountains of paperwork and administration needed to run the medical side of the home.

To the amazement of the coroner, she admitted destroying Mrs Derham's medical records after the pensioner's death claiming that she did not know the home had a legal obligation to retain the paperwork.

Vital charts detailing Mrs Derham's fluid balances were destroyed by Yelland, hampering any future inquiry into her death.

Other charts destroyed by the matron include those showing how often Mrs Derham was turned by nurses in a bid to prevent her developing sores.

Yelland told the inquest: 'I didn't realise we had to keep the charts.

'They were thrown away. I didn't realise they were a legal document.

'I genuinely didn't know - it was a system that was in place before I came.'

The inquest also heard that a vital mistake was made by staff at the home when the risk of Mrs Derham developing pressure sores was assessed.

An equation known as the Waterlo scale is used in such cases and takes into account many different variables. However, staff at the now-closed home failed to use Mrs Derham's age in the calculation and therefore she was not given the correct kind of mattress to sit and sleep on.

And when the terrible extent of Mrs Derham's condition was at last discovered, Yelland waited another two days before a doctor was called.

However, she admitted that it was clear Mrs Derham was seriously ill because a priest was asked to visit her.

Yelland claimed there were no signs Mrs Derham was dehydrated on the days leading up to her admission to hospital and said the feeding tube had become blocked when it was disconnected by ambulance staff.

She also claimed not to have noticed the foul stench coming from Mrs Derham's infected sores, which were continuously oozing pus.

She said: 'Mrs Derham was already frail when she came to us and I wasn't aware of any hydration problems.

'I didn't notice any difference in the smell although I did later on in the week.'

However, the coroner told her: 'You should have been aware of the state of the pressure sores, it was more than obvious.

'Your records were totally inadequate, records were missing and others were incomplete.

'The matron must take ultimate responsibility for the level of care given to patients.'

Care staff at the hospital, which had been bought by owner Norman Hurst 18 months previously, said extensive staff cuts which had affected morale had been made since the change of ownership.

Michelle Jensen told the hearing: 'When we were short-staffed, the patients were not getting the care they needed.

'Before Mrs Derham went into hospital, one of the nurses said: 'She is going downhill anyway'.'

Another carer, Cheryl Murdicroft, added: 'After the takeover we were short-staffed and continued to be so.

'People were phoning in sick all the time and not working out their notices.

'New carers tended to be in their teens and were poorly paid. Jane Yelland had slackened off under the new regime.'

Assistant Tracey Hyams said: 'Most of the time it seemed we could have done with some extra staff.'

Other care assistants revealed that since Mr Hurst had taken over control of the home, activities such as bingo for patients had been axed in cost-saving measures.