A former professional boxer had 20 falls in 10 months while in a Scots care home.
And after the last one in January 2021, Lawson Thain, 86, was left to sit in a chair in agony for almost four hours before medical attention was sought.
He was finally taken to Aberdeen Royal Infirmary by ambulance and died there from a combination of pneumonia and a broken hip two months later.
The Care Inspectorate have upheld five complaints raised by the family against Kingswells Care Home in Aberdeen.
Lawson had been a professional boxer, and while stationed with the army at Deepcut, Surrey, he trained heavyweight champ Henry Cooper.
Nine years after he was diagnosed with dementia he was admitted to a care home before being transferred to the Royal Cornhill Hospital for five years. In 2019 he was transferred to Kingswells.
Yesterday Lawson’s daughter Donna Ewen, 55, told of the horrifying last year of her father’s life in which he had repeated falls, despite there being warnings that he was at high risk.
He was also supposed to receive one-to-one care for several hours a day, yet two of his falls happened during this time. He was also supposed to have 30-minute checks.
The Care Inspectorate ruled he “did not experience safe and effective falls prevention and falls management” and also upheld the complaints on nutrition, personal care and grooming, inadequate safekeeping of his personal belongings and inadequate communication relating to his health, welfare and safety.
Donna said: “I was disgusted to find him in a state of disarray on admission to hospital after his fall.
"There was nose hair growing down to his lip, hair sprouting from his ears, untended finger nails, a heavily ulcerated mouth, he had cut his shin through his socks because of his long toenails and even more concerning, a dramatic weight loss.”
Donna added: ”His final year was the stuff of nightmares.”
A spokeswoman for Bon Accord Care which owns the care home said they “take any matters that have a negative impact on the people we support seriously”.
She added: “We are deeply sorry the care provided on this occasion fell below the standards expected.”
Don't miss the latest news from around Scotland and beyond - Sign up to our daily newsletter here.