Patient’s underwear, socks and shoes soaked in urine

Case Study 3

RESIDENT R was a 72-yearold who had been living with dementia.

Their relative first became concerned when they arrived at Dunmurry Manor and no one knew they were arriving.

The relative soon had concerns in relation to continence care — there was a strong smell of urine and they discovered their loved one was not wearing a pad and their underwear, socks and shoes were soaked in urine.

The resident was admitted to hospital in March 2016 and it became apparent that their neck muscles had wasted.

This was only three weeks after their admission to Dunmurry Manor.

A relative of the resident was told by hospital staff that they had a grade two pressure sore on her lower back.

She returned to Dunmurry and during a care review in October, a nurse found pressures sores were ungradeable — they were down to the bone.

The nurse said they were the worst pressure sores she had ever seen.

When the sores were swabbed, tests confirmed there was an E.coli infection present, however management was not aware that there was an E.coli outbreak in the nursing wing of Dunmurry Manor.

Morphine was prescribed but this was when she was already shaking with pain.

On one occasion, the relative arrived to find a soiled pad about three inches from her loved one’s head, very close to her face.

The resident’s airflow mattress regularly stopped working and on occasions the relative found it switched off or unplugged.

They were also concerned as the resident was not wakened for food or drinks, their hair became increasingly dirty and their teeth had become crusted over.