The inquest heard that wardmanager Sally Lewis became so concerned she went over Dr Eso's head by contacting the surgeon who carried out the operation.
While Ms Kostova had received general training in looking after vulnerable adults, she had not received specific training for dementia patients, wardmanager Sharon Matthews told the tribunal.
That led to a whole series of changes on the ward culminating in a new wardmanager being appointed in March, and I'm pleased to say that things are now improved significantly since that time.