It was only after 06:00 GMT that carers found Mrs Aitchison was no longer in her room, triggering a 30-minute search of the home.
“She had somehow accessed what should have been a locked fire door on the landing area and having gone through, fell down the stairs sustaining traumatic injuries from which she died,” Ms Mundy said in her report.
Mrs Aitchison was hypothermic when she was found, with the outside temperature “about -5 degrees”, the report found.
One of the witnesses who gave evidence during the inquest into Mrs Aitchison’s death said despite new systems being put in place at the home, there were still no formal checks carried out and “matters hadn’t changed” despite the care home manager claiming training had been given out.
Concluding her report, Ms Mundy invited the care home to consider further training of senior staff and a requirement for senior staff to each put in place clear processes for staff to respond to fire alarm activations.
She also recommended the training of carers, and any other relevant staff members, in terms of checking resident safety and fire door exits.
The company which runs the home, Pristine Care Group Ltd, has been approached by the BBC for comment.
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