A YORK pensioner who died three days after spending an hour-and-a-half in an ambulance on a journey which should have taken ten minutes was not the victim of a gross failure in care, an inquest heard.

Rosen Jackson-Virtue, 97, left York Hospital just after 3pm on a cold December day in 2001 wearing only a "summer dress" and two blankets, but did not arrive at St Olave's Nursing Home, in Olaves Road, York, until just before 5pm.

Three days later she died.

York Coroner Donald Coverdale

said there had been no gross failure on the part of people and organisations caring for her, and she had died of natural causes.

Ms Jackson-Virtue was discharged from York Hospital on December 10, 2001, and was supposed to be taken to St Olave's Nursing Home after it was decided she could no longer cope at home. But her home address at White House Rise was given to the ambulance crews, who took her there after dropping three other people off.

When they arrived the house was in darkness and the crews phoned back to the hospital and were told they were at the wrong address.

They arrived at the nursing home just before 5pm.

Sister Sharon Hurst, of York Hospital, told the court a sticker with Ms Jackson-Virtue's details had been put in the ward diary which was used for booking patient transport. But the nurse had failed to write in the diary the destination of the patient.

Sister Hurst said the ambulance crew had been told verbally she was to be taken to the nursing home. But Michael Gultnieks, who was driving the ambulance, said he had not been told of this.

Sister Hurst said procedures had since been changed and nursing staff now carried out a verbal check with the ambulance crews.

She said Ms Jackson-Virtue had been wearing a dress and cardigan at the time she was discharged and said, along with blankets, she was sufficiently insulated.

According to evidence given by Dr Alfredo Walker, who carried out the post-mortem, Ms Jackson-Virtue, did not have hypothermia and Mr Coverdale agreed with this.

Mr Coverdale said: "I do not find in this case, taking all the evidence into account, that there was gross failure by any person or persons or organisations to provide for her the necessary warmth, sustenance and food."

Updated: 10:56 Wednesday, April 16, 2003