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Coroner Blasts Care Home Over Pressure Sores
31 Dec, 2025
Summary
- Dementia patient developed sores due to lack of repositioning.
- A severe ulcer became unstageable by the time she returned to hospital.
- Coroner criticized care staff for the patient's preventable decline.

A coroner has sharply criticized care staff after a dementia patient, Ramona Harbott, developed severe pressure sores that contributed to her death. Mrs. Harbott, who had significant mobility issues, was discharged from hospital to Windmill Manor Care Home in Oxted, Surrey, on December 27, 2024. It was noted that she was not repositioned adequately during her stay at the care facility.
During her time at Windmill Manor, Mrs. Harbott developed sores. By the time she was readmitted to the hospital, one of these sores had progressed into an unstageable necrotic ulcer. Assistant Surrey coroner Susan Ridge stated that the damage was irreversible, even with subsequent treatment.
The running of Windmill Manor Care Home falls under Barchester Health Care Limited. The company has indicated it will not provide commentary until it has formally responded to the coroner's critical report. This incident highlights serious concerns regarding the care of vulnerable patients.




