"Systemic neglect" within the Isle of Wight NHS Trust contributed to the death of a 93-year-old Lake woman, an inquest has heard.

Joan Mary Shephard, of Bayview Court, Sandown Road, died at Mountbatten hospice on June 25, 2018.

An inquest into her death resumed at the Isle of Wight Coroner's Court last Friday (27), four and a half years after she was pronounced dead.

Coroner Caroline Sumeray told the court that the delays were down to Mrs Shephard's cause of death initially being attributed to sepsis of unknown origin, contributed to old age.

However, she said she was later made aware that she had been sectioned under the Mental Health Act in the final days of her life, which meant an investigation must be carried out.

As Mrs Shephard had already been cremated, this contributed to the delay.

The inquest heard how it was initially thought that Mrs Shephard, who was born in Harlesden, London, had a urinary tract infection (UTI).

After losing weight and her appetite, she began hearing voices, a condition which worsened, and she was taken to St Mary's Hospital.

Her family asked for her to be moved to a different ward but instead she was discharged from the MAU on June 15, which the coroner said should not have happened.

As she returned home, the voices started again.

Giving evidence in court, Dr Richard Braithwaite, a consultant psychiatrist at the Isle of Wight NHS Trust at the time, said another consultant requested his advice on June 15.

He said he tried calling the consultant "repeatedly", but couldn't get through so faxed a letter, but never heard back.

He was emailed on June 17, a Sunday, but was not working. The following day he made a request to go to see her at home that week. Meanwhile, her son, Ian, spent the Monday and Tuesday "begging" for someone to come and see his mother.

In hindsight, Mr Braithwaite said: "I wish they had called the on-call consultant at the weekend".

Isle of Wight County Press:

By June 20, Mrs Shephard was drinking less and the family's attempts to get her a drip installed, failed. 

"The system had ground to a halt", a statement from her son said.

"It seemed to me that they thought 'she is old, let her die at home'."

Dr Braithwaite, who now works for a different NHS trust, went to see Mrs Shephard later that day at her son's home in Calbourne and assessed her to be depressed and in need of medication.

He said he hoped that she would recover enough to be able to receive electroconvulsive therapy (ECT).

A statement from Ian read to the court said that if she had ECT on June 15, "she would probably be here today".

At 2am on June 21 Mrs Shephard was taken to Seven Acres and sectioned.

The next day Mrs Shephard's family were asked by a doctor about hospice care. They insisted the care plan was to be carried on, but it wasn't, they said.

Mrs Shephard was eventually taken to Mountbatten, where she died on June 25.

It was ruled that Mrs Shephard died by natural causes, contributed by systemic neglect.