The devastated daughter of a High Wycombe music legend broke down as she recalled the “horrific” suffering her father faced before he died of an infection that went undetected by his carers.

Peter Merrick Goodwin, 94, a classical musician who taught pupils in High Wycombe, had to be rushed to A&E when he was found by carers struggling to breathe and pleading “help me” at his home in Gibbs Close on the afternoon of June 13, 2020.

When he arrived at Stoke Mandeville Hospital, he was critically ill with urosepsis – a type of sepsis caused by an infection in the urinary tract – and despite the best efforts of the NHS, he died the next day.

Mr Goodwin’s daughter Mrs Grover sobbed as she recalled the pain his death had caused their entire family at an inquest at Buckinghamshire Coroner’s Court on Wednesday.

The inquest heard how Mr Goodwin, who had vascular dementia, was bed-bound and had a long-term catheter, would have visits four times a day from carers who would empty his catheter bag, provide personal care, get him food and his medication and make him comfortable.

But even though he had been seen by four carers on the day he was rushed to hospital – two at breakfast time and two at lunchtime - none of them had picked up that he was seriously unwell.

It was only when two further carers arrived just before 4pm they noticed that something was not right and called 999.

Notes by the carers, who worked for Mayfair Homecare in High Wycombe, were also contradictory on June 13 – with one lunchtime carer, who visited with a colleague at around 12.20pm, saying Mr Goodwin’s urine was darker than usual, while the other said it seemed clear.

Just hours later and when Mr Goodwin arrived at Stoke Mandeville at 5.29pm, doctors noted his catheter was covered in pus and his urine was dark and thick in consistency.

With a temperature of 38.4 and shortness of breath, it quickly became clear that Mr Goodwin was suffering from urosepsis – and had an associated kidney injury.

He was treated with oxygen and IV antibiotics but his condition continued to deteriorate so his daughter – who up until this point had been unaware her father had been taken ill – was called to the hospital to see him.

He passed away on June 14.

The quality of care given to Mr Goodwin by his care company was called into question at Wednesday’s inquest, with his daughter saying: “No one deserved to die like he did.”

She told the inquest: “He was a wonderful man who gave a huge amount to the High Wycombe community, but even if he was just plain old Joe Bloggs, no one deserved to die like he did.

“We’re talking about 2020 here, and my father died a horrific, isolating and terrifying death. It’s something I don’t think I will ever be able to reconcile.

“He was never given adequate care. We begged and argued constantly with social services about him getting appropriate care from people who were trained to deal with his physical health issues but also his advancing dementia.

“His carers were never of that calibre. It is desperately distressing that anyone in the western world should experience anything that comes close to what my poor dad did.”

Mrs Grover explained how, as her partner had been given a diagnosis at the beginning of lockdown that required them to shield, she relied on her father’s carers to look after him.

But Mr Goodwin’s neighbours Jeanette and Graham Smith had been monitoring when carers had been visiting because they were concerned they were not spending enough time with him.

They said: “When we were both furloughed, we noticed more about his care. We often heard Peter shouting out ‘please no’ or ‘please help’. His carers would only visit for 10 minutes sometimes.

“We would take in his medication when it was delivered and leave a note on the door for the carers to come to us to collect it.

“Sometimes we would have the medication for two days before someone would come. We would sometimes see them read the note and then just go inside anyway.”

After Mr Goodwin’s death, Mayfair Homecare carried out an investigation that found there were no signs of any negligence by carers – but senior coroner for Buckinghamshire Crispin Butler pointed out that care records for the months of May and June 2020 had been left at Mr Goodwin’s house, meaning the company had not accessed those critical notes as part of their investigation.

Buckinghamshire Council’s adult social care service also investigated, but Mr Butler said he would be writing to the council, Mayfair Homecare and the Care Quality Commission to highlight his concerns after the inquest.

He also highlighted how Mr Goodwin’s care records revealed on a number of occasions, carers were not spending the full 30 or 45 minutes they were allocated with him – instead spending just 10 or 15 minutes caring for him.

He said: “The evidence from the carers does not help me – there is one mention at lunchtime about the colour of Mr Goodwin’s urine from one carer, but the other said it was fine. But it is very clear something was evolving while he was at home.

“Changing [urine] bags and checking catheters was in the carers’ remit. It is very clear to me that when Peter arrived at hospital he was critically unwell but had been seen by carers that same day.

“Mayfair would not have been able to review the May and June records as part of their investigation because they had been left at Peter’s home.

“I will be writing a letter of concern as a result of the outcome of this inquest.”