AN elderly care home patient died of sepsis caused by bed sores after nurses failed to provide proper treatment.
Danielle Allan did not carry out a wound swab and failed to keep proper records relating to the woman’s pressure sore. David Paul also failed to perform a wound swab.
The failings contributed to the death of the woman, who was a resident at Beeches Care Home in Dunfermline, Fife.
At a disciplinary hearing of the Nursing and Midwifery Council (NMC), in Edinburgh this week, Miss Allan admitted a total of three charges and partially admitted another. Mr Paul admitted one charge.
An employee of the care home company who investigated the death of Patient A in February 2015 told the hearing she was “shocked” at Miss Allan’s unwillingness to take “accountability”.
Stephen McCaffrey, presenting the case on behalf of the NMC, said a post-mortem showed that the cause of death was sepsis, caused by a grade four pressure sore with other supplementary causes of death.
It had been documented in September 2014 that the patient was at great risk of developing a pressure ulcer. She complained to staff of a sore buttocks and by the end of January 2015 had developed a pressure ulcer.
On February 6 the patient was admitted to hospital and diagnosed with a grade four pressure ulcer. On February 14 she passed away.
The first witness at the hearing was Karen Johnson, Clinical Quality Manager for HC One, who carried out an investigation into the incident.
She said: “It became clear that we didn’t change the resident’s equipment. We didn’t respond to her care needs.
“The resident developed a grade three pressure ulcer and this was not reported by Danielle Allan or David Paul.
“Grade three or above is classed as a serious incident and a serious incident was not raised. I would have been made aware immediately.
“Normally a situation such as this would have been recorded on our incidence system.
“My main concern was that management were not aware until it was too late.
“Carers were aware of the pressure ulcer but assumed somebody else would have told the deputy manager.
“Danielle Alllan and David Paul were the primary carers. There’s a huge difference between a grade two and a grade three and nurses should be aware. They’re all trained in pressure ulcers.”
Mrs Johnson added: “When I interviewed Danielle Allan I was shocked she took no accountability.
“She had the attitude that there are lots of people involved. Which I agree with, but when you’re asking an individual about what could have been done, that’s not the answer I expected.”
Miss Allan admits that in January 2015 she failed to properly record the patient’s pressure ulcer.
Miss Allan accepts that she failed to complete the patient’s wound assessment chart and/or failed to document or record wound management and failed to implement a position change chart for the patient.
She also admits that she failed to carry out a wound swab on the patient’s pressure sore and failed to record the patient’s deteriorating wound on the home’s online system following the development of a grade three pressure sore.
The charges make clear that these admitted failings all contributed to the death of Patient A.
Mr Paul, admits failing to carry out a wound swab on the patient’s pressure sore, also contributing to her death.
Miss Allan denies the rest of the charges against her, including failing to escalate the patient’s deteriorating condition to management, and that her fitness to practice is impaired.
Mr Paul is not present at the hearing but denied in writing the rest of the charges.
Miss Allan’s representative, Natalie McCartney, suggested to the hearing that she had not been given proper training in dealing with this type of situation.
She asked Mrs Johnson: “Would it be a surprise to hear that Miss Allan received no training from the manager of deputy manager?”, to which Mrs Johnson replied: “Yes it would, that’s not our expectation.”
She then asked Mrs Johnson: “Do you find it believable that both the manager and the deputy manager were not aware of the pressure ulcer?”
She answered: “I was very surprised because I would expect everyone to know that.”
Mrs Johnson admitted that there were failings on the part of the home and that the incident has forced the company to alter their processes.
The hearing continues.
Beeches Care Home is run by healthcare management company HC One, who last month were ordered to pay almost £60,000 in fines and costs after a woman suffered a serious burn while in the care of Elmwood Nursing Home in Croydon, south London.
HC One said they were “deeply disappointed when the significant shortcomings of two former members of staff came to light in 2015”.
They added: “The individuals involved were subsequently dismissed, and we referred them to the Nursing and Midwifery Council so their registration could be reviewed.
“The behaviour of these individuals went against everything we stand for as an organisation, and we have apologised unreservedly to the family for the tragic result of these shortcomings.
“This tragic incident was the result of two former employees who failed to follow our robust training and safeguarding processes, and is in no way representative of the high standards of care we continue to provide to residents.”
