He had been put to bed at 9pm by staff and began crying for help at 10.05pm but stopped at 11.15pm.

Ms Ridge said: “For much of this time staff were undertaking their nighttime routine. However, the evidence revealed that a carer heard his cries at [11.05pm] but she did not open the door or go into his room as it was said she was frightened of him.”

Mr Batchelor was found dead shortly before 11.30pm. The coroner recorded a narrative verdict that he died of an accident contributed to by neglect. The medical causes were “positional asphyxia” and pneumonia. Ms Ridge heard that since this incident, the care home has briefed staff about the need to check on residents by going into their rooms.

But the company has not explained to staff what they should do if they are “frightened or concerned about entering a room on their own”. The inquest heard the bed had a mattress extension fitted at the foot end but this fell through the frame when Mr Batchelor manoeuvred himself during the night.

The coroner said it was supposed to have a deck in place which would have prevented the fall, but the care home was unaware of this. In a Prevention of Future Deaths report, Ms Ridge said: “The bed did not have a deck in place supporting the mattress extension. The extension fell through the frame and Mr Batchelor became wedged in the gap.”

The court heard the care home has ensured beds are fitted with support.