Source · Prevention of Future Deaths
Dorothy McDermott
Ref: 2015-0266
Date: 10 Jul 2015
Coroner: Simon Nelson
Area: Manchester (North)
0 responses identified · 4 indexed addressees
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AI-generated concerns summaryThe coroner noted the inappropriate placement of a vulnerable individual in a residential care home that lacked nursing care and pressure sore training for staff. There was concern that availability was prioritised over the suitability of the placement, and formal guidance is needed for agencies.
Date
10 Jul 2015
56-day deadline
4 Sep 2015 est.
estimated from the report date
Responses identified
0 of 4
Coroner's concerns
The coroner noted the inappropriate placement of a vulnerable individual in a residential care home that lacked nursing care and pressure sore training for staff. There was concern that availability was prioritised over the suitability of the placement, and formal guidance is needed for agencies.
View full coroner's concerns
Dorothy McDermott was 80 years old. She had been housebound for 234 years. She had been diagnosed with a urinary tract infection and was confused. On the 17 th January 2015, she had fallen three times whilst at home. Paramedics advised a rapid response but they finished at 5.3Opm. Mrs McDermott required a place of safety. Following discussions between the Local Authority’s emergency duty team and the out of hours service for the district nursing team, emergency respite care was arranged at the Littleborough Care Home to which Mrs McDermott was conveyed during the early hours of the 18 th January. It was envisaged that Mrs McDermott would be reassessed on the 19 th January. The Littleborough Care Home offered residential but not nursing care. Care staff at the home were not trained in either the examination for or care of pressure sores. That placement was inappropriate. The rationale for that decision was one of availability with the facility of a ground floor bedroom which had been newly decorated. Whilst appreciating that the decision to procure respite care was made ‘out of hours’ the overriding concern given the extent of Mrs McDermott’s vulnerability should have been to obtain a suitable placement which guaranteed a place of safety. Whilst not wishing to be prescriptive, formal Guidance is required to as to ensure that vulnerable individuals are appropriately placed by the Agencies involved.
Report sections
Investigation and inquest
On the 10 th February 2015 I commenced an investigation into the death of Dorothy McDermott for whom the cause of death was confirmed at Inquest as being that of la) Septicaemia, lb)Decubitus Ulcer / Bed Sore with Hypertension and Urinary Tract Infection, whilst not causative of death, being contributory factors under 2. At an Inquest convened on the 2 nd July 2015 the following conclusion was made
— ‘Against a background of increasing immobility and susceptibility to urinary tract infections, Dorothy McDermott was at high risk of developing pressure sores. On the 17 th January 2015, having fallen three times that day, she was admitted from home to emergency respite care where she remained until the 26 th January. She was not examined when attended upon by a GP on the January and subsequently opportunities to examine her sacrum were missed by reason of inadequate training of care staff. The evidence does not show when the Grade 4 pressure sore developed but more likely than not, it would be over a number of days prior to the 26 th January on which date a visiting District Nurse was alerted to concerns raised by care staff by which time Mrs McDermott was already in extremis. She was admitted to Fairfield General Hospital where she died during the early hours of the 27 th January 2015’.
— ‘Against a background of increasing immobility and susceptibility to urinary tract infections, Dorothy McDermott was at high risk of developing pressure sores. On the 17 th January 2015, having fallen three times that day, she was admitted from home to emergency respite care where she remained until the 26 th January. She was not examined when attended upon by a GP on the January and subsequently opportunities to examine her sacrum were missed by reason of inadequate training of care staff. The evidence does not show when the Grade 4 pressure sore developed but more likely than not, it would be over a number of days prior to the 26 th January on which date a visiting District Nurse was alerted to concerns raised by care staff by which time Mrs McDermott was already in extremis. She was admitted to Fairfield General Hospital where she died during the early hours of the 27 th January 2015’.
Circumstances of the death
As above
Copies sent to
1. The Department of Health2. Rochdale MBC3. Pennine Care Trust4. Littleborough Care Home
Similar PFD reports
Report details
- Reference
- 2015-0266
- Date of report
- 10 July 2015
- Coroner
- Simon Nelson
- Coroner area
- Manchester (North)
Responses identified
Responses identified
0 of 4
4 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 4 Sep 2015 (estimated from the report date).
Sent to
- Department of Health and Social Care
- Littleborough Care Home
- Pennine Care Trust
- Rochdale Metropolitan Borough Council