Ivy Atkin death: 'Chaos' at Autumn Grange care home
A care home where a woman became severely underweight and later died was "chaotic" during an unannounced inspection, an inquest has heard.
Ivy Atkin, 86, died of pneumonia in November 2012 after being transferred from Autumn Grange home in Nottingham.
Owner Yousaf Khan was jailed for three years two months in February after admitting corporate manslaughter.
The inspection came after a whistleblower alerted the city council's safeguarding team.
Mrs Atkin weighed under four stone (25kg or 3st 13lbs) when she died.
Care Quality Commission (CQC) inspector Lesley White told the inquest that residents were "sat in dirty clothes, in their own urine".
The home, on Sherwood Rise, was full of "chaos and screaming" during her inspection, she said.
Under questioning from Nottinghamshire Assistant Coroner Stephanie Haskey, Mrs White said she had not "missed anything" in an earlier inspection in September.
"A home can go downhill quickly," she told the inquest at Nottingham Council House.
The care home had a history of care plan failings and had already been inspected by the CQC and other agencies, the inquest was told.
In February 2012, the home had a warning about infection control and cleanliness.
Six months later, a staff member said there was no Criminal Records Bureau check on her while she worked there.
Then in October, there was a fight between two residents where one was injured and taken to hospital. Also two night staff were dismissed.
Relatives of other residents said the home tried to side step their concerns, the inquest heard.
Khan, 47, of Nelson Road, Nottingham, was jailed and his firm Sherwood Rise Ltd, was fined £300,000 for corporate manslaughter - the first case of its kind in England.
The inquest heard Mrs Atkin died from pneumonia as a result of debilitation and low body mass index (BMI), contributed to by dementia.
Her BMI was just 10.7, while the healthy weight range is between 18.5 and 24.9.
CQC inspectors found the care home did not meet any of their required standards including safeguarding service users from abuse, meeting nutritional needs, cleanliness and infection control.
Mrs Atkin and the other residents were moved out on 4 November, but she died on 22 November.
The inquest continues.