Claims made by Janet Noon's sons against care staff, an ambulance crew and her GP were examined at an inquest at Norfolk Coroner's Court this week.

Concluding the inquest, assistant coroner Robin Weyell said the 73-year-old had died as a result of a pulmonary thromboembolism - a naturally occurring condition.

He also found that none of the concerns raised by her family had caused or contributed to her death.

Belvoir House care home, Brundall (Image: Google Street View)

Mrs Noon, who had been diagnosed with dementia in 2020, died on February 12 last year while a resident at Belvoir House, Brundall.

Mr Weyell described her as "much loved by her family and friends".

"She was a hardworking and selfless individual with a strong faith who always put everyone first and every job or role she took on was centred around helping people," he added.

“As long as what she was doing was working towards her goal of helping others she was happy, a reflection of her Christian faith and charitable spirit.

“I do not find her death was in any way preventable."

Coroner Robin Weyell. (Image: Denise Bradley)

The inquest examined concerns raised by Mrs Noon's son, Jonathan and James Wedon, about the circumstances leading up to her death. This included decisions made by care home staff, ambulance clinicians and her GP, Dr Wendy Clark of Brundall Medical Practice.

Mr Weyell acknowledged the importance of those concerns being brought forward, and said: "I commend Janet’s sons for raising the issues they have."

However, after hearing all the evidence, he concluded there was no link between those concerns and Mrs Noon’s death.

“I do not find that there is evidence to the appropriate level of confidence that this omission ... caused or contributed in any way to Janet’s death,” he added in relation to concerns about communication with the family on the morning she deteriorated.

The court heard that Mrs Noon’s sons held power of attorney for her health and welfare, and questions had been raised about whether they should have been contacted earlier as her condition worsened.

While the coroner noted that “staff did not contact them immediately when issues concerning Janet’s declining health were identified”, he found this did not impact the outcome.

Evidence was also heard about conditions within the care home in the days leading up to her death.

The inquest was told that a lift in the home had broken down on February 3, preventing Mrs Noon gaining access to the ground floor.

“Despite the breakdown of the lift Janet was able to walk around a number of corridors and rooms on the first floor," Mr Weyell said.

"There was a room across from her that she could have access to.

Janet Noon (Image: Courtesy of family)

“I find no evidence that the absence of a lift caused or in any way contributed to her death.”

He also noted that Mrs Noon had experienced falls in previous months and had been assessed as not safe to use stairs independently and that efforts to encourage stair use had increased her anxiety.

In the days before her death, the court heard Mrs Noon had reduced her food and fluid intake and had become increasingly weak.

By the morning of February 12, staff noted she was more unwell, prompting observations which indicated a possible infection. An ambulance was called at 7.51am.

Paramedics assessed Mrs Noon and did not identify immediate signs of a life-threatening condition despite her being "undoubtedly unwell".

However, there were no clear symptoms pointing to a pulmonary embolism at that time.

Mrs Noon's GP was consulted and she recommended she remain at the care home for hourly observations until she could arrive later to test a urine sample.

But tragically, just minutes after paramedics left, Mrs Noon’s condition suddenly worsened and she became unconscious.

Paramedics returned from the carpark to her room but did not attempt CPR in line with respect form instructions. She died at 11.45am.

Janet Noon with her son Jonathan and his wife Natalie on their wedding day (Image: Courtesy of family)

Summing up the evidence, Mr Weyell said that while there had been areas where care could have been improved, none reached the threshold required to establish a link to causation.

“This was a naturally occurring condition,” he said, noting that the care staff, paramedics and GP were not to blame.

“The concerns raised have been fully explored, but I do not find that any of those matters caused or contributed to Janet Noon’s death.”

© Norwich Evening News