Disabled woman died after ‘gross failures’ by nurses
NEGLECT by care home nurses contributed to the death of a disabled woman days after she had all her teeth surgically removed was, a coroner has concluded.
Rachel Johnston, 49, had her teeth extracted at Kidderminster Hospital on October 26, 2018 due to severe decay, which had been causing her pain and difficulty eating.
Despite being happy and “singing” to herself on discharge, she fell asleep on the journey back to Pirton Grange Care Home, near Pershore, Worcestershire and never regained consciousness.
She died two weeks later after her family decided to withdraw life support. Senior coroner David Reid found “gross failures” by two nurses at the care home amounted to a failure to provide basic medical care, contributing to Miss Johnston’s death.
Delivering a narrative conclusion at Worcestershire Coroner’s Court, Mr Reid said: “Rachel died as a result of complications of necessary surgery, to which neglect contributed.”
He added the failure of a 111 outof-hours clinician to ask “direct questions” about her condition over the phone the day after her discharge amounted to a lesser care failure.
The coroner heard that the home’s record-keeping was patchy and observations were not routinely recorded.
He said care home nurses failed to carry out basic physiological checks, then failed to seek emergency medical care quickly enough.
The coroner said care home healthcare professionals Sheeba George and Gill Bennett failed to routinely check Miss Johnston’s pulse, heart rate and blood oxygen levels after the surgery. It was not until Sunday October 28, at 2pm, that staff dialled an ambulance.
Mr Reid said: “I am satisfied that if Rachel had been admitted to hospital that (Saturday) evening, she would probably have survived. It follows the two gross failures which I have identified did indeed contribute to Rachel’s death on November 13, 2018.”
A post-mortem examination found she died after her brain was starved of oxygen. Ms Johnston, who suffered brain damage after contracting meningitis as a baby, had been asleep for 42 hours before staff raised the alarm.
Scans at Worcestershire Royal Hospital showed she had suffered an irreversible hypoxic brain injury.
Lawyers for the care home said procedures had since been tightened.
A NEW £24 million interchange for the West Midlands Metro and bus services has been given the go ahead.
New images have also been released of the ‘Dudley Interchange’ project which will be built on the site of the town’s existing bus station.
The approval of the full business case means West Midlands Combined Authority can now work on designs for the hub which will link up with the new £450 million metro tram extension currently under construction
between Wednesbury and Brierley Hill. It will also have cycle parking and retail units alongside the transport facilities.
Both projects are due to be completed in 2023 and there are plans in the long-term for the new ‘Sprint’ bus network to use the facility as well.
Transport for West Midlands is leading on the project in partnership with Dudley Council.
The majority of the funding is coming from the region’s Transforming Cities Fund allocation, topped up with contributions from the council and combined authority. West Midlands Mayor Andy Street said: “Like other town centres, Dudley has been hit hard in recent years which is why the combined authority is putting its cash to good use to help revitalise the borough.
“We are committed to doing what we can to support the council in bringing their masterplan to life. “That’s why I am delighted we have approved even more funding for Dudley, with the new interchange set to provide a fitting gateway to what will be a revitalised and reborn town centre.”
Among the other schemes planned for Dudley are the £82 million ‘Portersfield’ project comprising 12 acres of retail, entertainment and student and residential accommodation on the former Cavendish House site.
There is also the new £31 million Leisure Centre and £26.8 million Black Country and Marches Institute of Technology.