The death of a beloved mother and grandmother who died of hypothermia in the garden of a care home is under investigation.

In the early hours of January 7, 2022, 96-year-old Joan Chapman was found dead in the garden of Coombe End Court Care Home in Marlborough, after it’s believed she unlocked a door and walked outside, unnoticed, in sub-zero temperatures.

But an inquest held at Wiltshire and Swindon Coroner's Court, which began on Monday, November 25, is investigating her death after it was found an alarm on the door she went out of had been disabled that night.

The Great Bedwyn local, who enjoyed gardening, baking, and attending church, first moved to Coombe End Court’s specialist dementia unit, run by the Order of St John Care Trust, in 2019.

Joan’s family say they placed her in the Marlborough care home because they felt it would be “safer for her” after she developed dementia and began having falls.

Joan Chapman was a beloved family member who was a keen gardenerJoan Chapman was a beloved family member who was a keen gardener (Image: RWKGoodman) At the start of the five-day inquest, area coroner Ian Singleton noted how: “The door alarm had gone off just before 10.30pm when a resident went outside, and after bringing them back in, the carer had not reset it.

“Joan was supposed to be checked on every two hours throughout the night due to her dementia and high risk of falls.

“The care home said that the locks on the windows and doors are to be checked every few hours.”

A tick sheet submitted to the court from the night of Joan’s death shows that this had been ticked at every interval leading up to her death.

But when shown the sheet, Ms Fernandes, the night shift carer who found Joan deceased, responded: “I don’t know who wrote that.”

A separate tick sheet marking when each resident's room had been visited throughout the night was submitted to the court, and showed some marks had been crossed out.

In interview, Ms Fernandes said: “I did cross it out after she had been found dead outside.

“I didn’t reactivate the alarm on the door because if a resident went out I didn’t want the alarm to go off again.”

PC Alexander Bell, who attended the care home on the morning of Joan’s death, also noted: “The doors were not difficult to open.

“The lock on the door Joan is believed to have gone out of did not need a key and could be unlocked by twisting it."

As the investigation continues into the details of Joan's death, her family have now paid tribute to “a loving grandmother, great grandmother and mother.”

"Although she was suffering from dementia, she was a very happy and popular lady," said a member of the family.

"She spent most of her life living near Great Bedwyn where she was an active member of the local community.

"She regularly attended St Katherine’s Church where she was well known for arranging flowers for the local weddings, and she won many awards for her delicious apple pies.

"Her family was very important to her and in later life she loved playing with her great grand children. 

"She is sadly missed by us all."

Joan's daughter added: “We as a family hope that any failings of the care system in mum's case can be fully investigated and highlighted so this tragedy does not occur again and proper guidelines are implemented and followed.”

Joan’s inquest will continue in front of a jury at Wiltshire and Salisbury's Coroner's Court throughout the week, and the conclusion is set to be drawn on Friday, November 29, 2024.