Instead he was visited four times a day at home by agency workers, who are accused leaving the pensioner in baking temperatures during the summer heatwave and failing to ensure he was drinking regularly.
Coroner Mary Hassell concluded Mr O’Neill was suffering from pneumonia, heatstroke, and dehydration when he died on August 12 last year.
“If he had been properly hydrated and had been in an appropriately cool environment, he would not have died when he did”, she concluded in her inquest report.
She has written to the care agency which was looking after Mr O’Neill, Care Outlook Ltd, demanding changes to avoid similar deaths in the future.
“Mr O’Neill was attended by carers from Care Outlook four times a day. It was noted that he was very hot and he was brought a fan”, she wrote.
“He was also offered respite care in a care home. However, he was fearful of catching Covid-19 and in 2020 care home COVID death rates were very high.
“When Mr O’Neill refused a place in a care home, the Care Outlook staff did not do anything to resolve the fault with Mr O’Neill’s heating, so it remained on in the middle of a heatwave. An engineer was called to fix his door hinge, but not his heating.
“Mr O’Neill desperately needed a reduction in the temperature of his flat, first and foremost by the heating being fixed, but Care Outlook staff did not deal with this.
“He also needed immediate rehydration.”
Ms Hassell said Mr O’Neill had been offered drinks by care staff at mealtimes, but he “needed constant prompting and encouragement to drink enough”.
“His deterioration was not recognised”, she concluded.
Copies of her report, which demands a response by early April, have also been sent to Hackney Council and the Care Quality Commission.
According to Office of National Statistics and CQC figures, there have been more than 26,000 care home deaths from Covid-19 since the start of the pandemic.
However just eight care home deaths have been recorded in the borough of Hackney.
Care Outlook Ltd has been contacted for comment.