Poor oral hygiene played a part in the death of an elderly care home resident, an inquest was told.

And after hearing that more regular and stringent checks were now being carried out at the Wynne Rest Home in Old Colwyn, Joanne Lees, assistant coroner for North Wales East and Central, called for two updates in the next 12 months on how the improvements were being implemented and monitored by Conwy County Borough Council.

Alfred Pilbeam, 79, who was registered blind, died at Glan Clwyd Hospital on February 25, 2018, four days after being admitted after Kath Longmire, manager of the care home, became concerned about his deteriorating condition.

She called GP Dr Dylan Parry, who told the inquest in Ruthin that Mr Pilbeam had a suspected urinary tract infection.

The pensioner had a history of heart problems and swallowing difficulties and was on a “soft diet”, with thickener in fluids.

Dr Parry said he was dehydrated and had a white coating on his tongue and inside his cheeks.

“I was struck by how unusual it looked and I was not 100 per cent sure what it was,” he said. “I thought it might have been thrush or the residue of medication.”

Mrs Lees asked him: “Were you not concerned with the presentation and whether it could have related to his care at Wynne Crest?”

Dr Parry replied: “No. I was not sure what was causing it.”

Mrs Lees: “Did you have any concern about his oral hygiene?”

Dr Parry: “Yes. It struck me how abnormal the appearance was.”

He arranged for Mr Pilbeam, a model railway enthusiast, to go to hospital , where doctors described him as having “very poor mouth care”, with a “hard, yellowish-green thrush”.

Mrs Longmire told the inquest that Mr Pilbeam, like other residents, was assisted twice a day in brushing his teeth though he had only three upper teeth. When she saw the coating in his mouth she tried to remove it but he wouldn’t let her but he had not complained about any pain or having a sore mouth.

Pathologist Dr Huyam Abdel Salam gave the cause of death as partial respiratory tract obstruction and pneumonia, with poor oral hygiene a contributory factor. He also had a urinary tract infection.

A safeguarding investigation was carried out after Mr Pilbeam’s death but Mrs Sian Wyn Jones of Conwy County Borough Council, said that while improvements to record-keeping were recommended it was concluded that there had been no neglect.

Mrs Longmire told the inquest that more rigorous oral health checks were now carried out at the home.

Recording a conclusion of natural causes, Mrs Lees commented: “I do find that the infection in his mouth was present on the 21st , the day of his admission to Glan Clwyd Hospital, but I cannot say how long it had been there..

“It is clear there was poor oral hygiene but I cannot say whether it was because x or y was not done. Poor oral hygiene can occur naturally or unnaturally.”