Woman's bedsores "horrified" care home staff
PUBLISHED: 10:21 24 November 2011
"I have been a nurse for 29 years but I can count on one hand the times I've seen a pressure sore with such severity," she said.
"I was horrified at the pressure sore," Ms Porter said. Asked on a scale of one to 10 how much pain Ms Dunmore had been in, Ms Porter replied: "10."
GROSS failings to turn an elderly woman suffering from severe bedsores at a Littleport care home did not directly cause her death, a coroner has ruled.
But coroner David Osborne said failure by staff at the Old Vicarage care home to turn 74-year-old Ana Dunmore “could be regarded as gross”.
He was, however, unable to pass a verdict of neglect because there was not clear evidence to suggest the bedsores resulted in Mrs Dunmore’s death on July 11 2009.
“There is no evidence to support that the failure to turn Ana Dunmore in itself caused her death,” he said.
“In the light of the evidence I am unable to make a finding of neglect in the narrow sense of coronial law.”
He instead recorded a narrative verdict after ruling that the “pressure sore was a contributing factor but not a direct cause”.
Speaking after the case Mrs Dunmore’s daughter, Bergonia Hammond said: “We would have liked a neglect verdict. That’s what we wanted.”
However she said she was relieved the inquest was over and the verdict had not been determined as natural causes.
Ms Dunmore died in 2009 after suffering from a range of conditions including pneumonia, Parkinson’s Disease and dementia.
She was already at “high risk” due to the fact she suffered from a large number of conditions, the inquest at Huntingdon Magistrates’ Court heard.
Mr Osborne said Mrs Dunmore, of Howdale Rise, Downham Market, was not turned for nine days despite a turning regime being put in place following a diagnosis of a Level Four bedsore, the worst kind of rating.
A spokesperson for The Old Vicarage said staff were “deeply saddened” by Mrs Dunmore’s death but said: “We can confirm we have already implemented a range of measures to improve record keeping at the home.”
“Although it is important to recognise that a number of other factors and agencies also played an important role in what was a distressing sequence of events, four our part, it is with deep regret and sorrow that mistakes were made and immediate lessons were learned.”
The inquest also heard how it took several days to transfer Mrs Dunmore from the Old Vicarage to Holmwood House care home, in Swaffham, Norfolk, while needs assessments and a funding application for an ambulance transfer were carried out.
The inquest also heard from several people involved in the care of Ms Dunmore, including care assistant Annette Porter who told the hearing: “I wish we could have done more for her.”
Annette Porter said she was “quite unhappy” about the situation surrounding 74-year-old Ana Dunmore’s care prior to her transfer to Holmwood House care home in Swaffham, Norfolk in 2009.
Ms Dunmore developed a bedsore described by Ms Porter as the worse she’d seen in nearly three decades of nursing.
“I have been a nurse for 29 years but I can count on one hand the times I’ve seen a pressure sore with such severity,” she said.
“I was horrified at the pressure sore,” Ms Porter said. Asked on a scale of one to 10 how much pain Ms Dunmore had been in, Ms Porter replied: “10.”
Consultant pathologist Dr Martin Goddard, from Papworth Hospital, said the sore would have contributed to her high level of risk.
However, he added: “She had a lot of significant risk factors behind her.
“It’s hard to say whether the sore was significant. I would err on it being not a huge amount because of the other risk factors present.”
Inspectors from the Care Quality Commission had visited the home and reported that they were “surprised” that no one at the Old Vicarage had turned Ms Dunmore for nine days despite putting a monitoring system in place. They made recommendations that resident care plans be much more detailed after a random inspection precipitated by events surrounding Ms Dunmore’s care.
Carolyn Loveday, from Littleport Health Centre, was called in to help with Ms Dunmore’s care on June 14, 2009.
“I asked for an urgent review and placement in a nursing home as I felt she wasn’t receiving enough care for her needs,” she told the inquest.
“The pressure sore had developed to that extent and no one had spotted it.”
But the inquest heard that Ms Dunmore could not be admitted to the Prince of Wales Hospital in Ely because she did not meet the correct criteria.
She also had to wait a number of days to be transferred to Swaffham so a nursing needs assessment could be carried out, along with an application for funding for an ambulance transfer.
Ms Loveday added that health check procedures have been changed following Ms Dunmore’s death.
Care assistants said they only “cursorily looked” at charts designed to record how often Ms Dunmore was turned.
However Ms Loveday told the coroner’s court: “Subsequently the Trust has looked at that and now advises we look at them.”