Care‘ well below acceptable levels’
THE care given to a patient who died of blood poisoning was “unacceptable”, a coroner claimed.
Tegwen Roderick’s care at Ysbyty Cwm Cynon was described as “well below acceptable standards”.
A CORONER has labelled the hospital care of an 88-year-old patient who died of blood poisoning as “unacceptable”.
A review is set to be launched at Cwm Taf Health Board following the death of Tegwen Roderick on June 4, 2014.
An inquest on Friday described the pensioner’s care at Ysbyty Cwm Cynon in Mountain Ash as falling “well below acceptable standards.”
The hearing was resumed by Coroner SarahJayne Richards at Aberdare Coroner’s Court on Friday, October 21.
Delivering a narrative conclusion she said Mrs Roderick, from Abercanaid in Merthyr Tydfil, died as a result of sepsis – commonly known as blood poisoning – associated with an inflammation of the large bowel.
She had also suffered fractures of the right tibia and fibula bones, associated with a pressure ulcer and inflammation of the bone.
The pressure ulcer was on the patient’s right leg, and was caused by rubbing against a plaster cast used to protect an original injury on the patient’s left leg.
The breaks to Mrs Roderick’s right tibia and fibula occurred at the Mountain Ash hospital, but the coroner concluded she was confident there was “no intention to cause harm.”
However, the injury could have happened when one nurse at the hospital – rather than two – turned the fragile patient over in bed.
In June 2014, that injury was “unexplained” and four people were arrested during a police investigation.
Cwm Taf Health Board initially suspended 10 members of staff. In January 2016, the Crown Prosecution Service declared no further interest in the case.
In summary, the coroner said: “To what extent did the failure to apply appropriate dressings at the correct time intervals contribute to this ulcer escalating and becoming infected, and finally the role of poor nutrition, known to be important in improving skin integrity?
“The view has been expressed that often nursing care was provided but simply not recorded or that writing was illegible – either way this is unacceptable and in breach of hospital policy and the duty of care that was owed to Mrs Roderick.”
Friday’s inquest heard how Mrs Roderick was first admitted to A&E at Prince Charles Hospital in Merthyr Tydfil on April 3, 2014, following a fall at home.
At the time she was treated for a fracture of her left femur.
The court heard she had been suffering with dementia for several years, was bed-bound and very frail.
She was transferred to Ysbyty Cwm Cynon in Mountain Ash on April 18, 2014, and was described as “stable” until nurses found a pressure sore on her right shin ten days later.
By May 12 the wound was found to be infected and was declared a Stage 4 pressure ulcer.
Then on May 29, nurses found the “unexplained” injury – a transverse compound fracture to her right tibia and fibula, with an 8cm by 6cm wound.
It had occurred some time on May 28 or May 29.
She was immediately transferred to Prince Charles Hospital and underwent an operation.
South Wales Police were informed about the injury on May 30. The patient died in the early hours of June 4.
Pathologist Andrew Davison, who carried out a post-mortem examination, noted that the leg break which occurred at Ysbyty Cwm Cynon happened with a twisting force. It would have required “minimal” force due to her frail condition and osteoporosis – and noted the fracture had “shortened her life.”
He concluded the immediate cause of death, in his opinion, was sepsis from two sources.
A report by Doctor Richard Bailey, an independent medical expert said nurse Debra Bentley, who worked the night shift on May 28-29, said she was unaware about the fracture.
Mrs Roderick was required to be turned to help avoid sores at regular intervals by two nurses, but Ms Bentley undertook the last turn at 6.45am on May 29 on her own.
Nurse Jackie Davies took over Mrs Roderick’s care on May 29 and found the compound fracture.
The report from the medical expert concluded as Mrs Roderick was so fragile, the right leg break is likely to have taken place when a nurse or nurses were dressing the wound on her shin, or turning her over in bed.
It was noted her vulnerable leg may have been left unsupported when one nurse – and not two – had turned her over.
Jason Roberts, assistant director of nursing at Cam Taf Health Board, confirmed staff levels “were appropriate” at the time.
He said “by default and definition” Mrs Roderick’s graze on her shin “should have been classed as a high grade pressure area”.
He added: “I think, and it is my opinion, that the nurses were working towards the graze, and didn’t appreciate the significance of it.”
A family statement issued after the inquest said: “The family are pleased the inquest into our Aunt’s death has finally taken place.
“We are disappointed this process has taken so long because of the police and Crown Prosecution Service investigation.
“We wish to specifically thank Doctor Richards for her rigorous review of the circumstances surrounding our Aunt’s death.
“The care our Aunt received fell well below acceptable standards in many areas and would indicate failings in care and review of care at ward, hospital and Board level.
“We agree with Dr Richards’ findings and trust that the Cam Taf Health Board will ensure the necessary changes indicated in the action plan are fully implemented.”
Meanwhile a review of the implementation of Cwm Taf Health Board’s action plan in improving patients’ care will take place on March 30, 2017.