A CORONER’s letter revealed a catalogue of errors at a care home as a man lay dying, including staff mistaking paramedics for engineers and taking them to fix a broken lift.

It also revealed a nurse waited 32 minutes before calling an ambulance after seeing the 81-old patient was struggling to breathe, staff forgot the security code so paramedics were left waiting outside and no employees at the home waited with the patient as resuscitation was attempted.

Henry Williams suffered a cardiac arrest at the Castlebar Care Home in Sydenham Hill on February 12 last year at around 3pm, two days after being released from Lewisham Hospital.

Following an inquest at the Inner South London Coroners on February 18, coroner Dr Andrew Harris wrote to the home's manager Terry O’Connor, asking for action to prevent similar situations.

Dr Harris said: "The nurse in attendance in the home gave evidence there was a delay of 32 minutes before her attending Mr Williams and her calling an ambulance, during which time two staff and the on call GP were consulted, even though she wished to call one.

"One ambulance crew reported 15 minutes' delay in accessing the nursing home as the security code was known to them and staff did not know they were there.

"Another ambulance crew reported they were thought to be lift engineers and taken to the broken lift by staff."

Dr Harris also drew attention to the confusion over the mental capacity of Mr Williams and the instructions for whether or not he should be resuscitated.

The letter, copied to the Lord Chancellor and Lewisham Healthcare Trust, asked Mr O’Connor to make changes to staffing, staff training and emergency care policies.

Dr Harris returned a verdict of death by natural causes.

A response from Mr O’Connor dated March 18 described various changes the home had made to improve visits from emergency services and mentioned they had recently gained a Gold Standard Framework status for end of life care in homes.

The owner of the home, Excelcare, was unavailable for comment.