Joan Chapman,96岁,死于体温过低,因为她通过一扇没有锁的门离开照料家庭;调查发现重大缺陷。 Joan Chapman, 96, died of hypothermia after leaving her care home through an unlocked door; inquest found major failings.

96岁的Joan Chapman 在离开马尔堡的Coombe终院护理之家后 死于体温过低 Joan Chapman, 96, died of hypothermia after leaving Coombe End Court Care Home in Marlborough, through an unlocked door in cold temperatures. 调查发现,圣约翰关怀信托基金会管理的护理之家存在重大缺陷,包括不锁门、忽视警报、工作人员培训不足。 An inquest found the care home, run by the Order of St John Care Trust, had significant failings including not locking doors, neglecting alarms, and poor staff training. 此后,该信托机构采用了电子检查、改进培训和新的安全措施。 The trust has since introduced electronic checks, improved training, and new security measures.