Mrs Clarke “Betty” · Prevention of Future Deaths report

On the 2nd January 2015 I commenced an investigation into the death of Gwendoline Betty Clarke. The investigation concluded at the end of the inquest on the 7th June 2016. The conclusion of the inquest was an open conclusion and a narrative conclusion. The medical cause of death was 1A respiratory failure, sepsis, and pancreatitis in a woman with diabetes, 1B bilateral femoral fractures.

Mrs Clarke “Betty” was an 89 year old lady who had a significant medical history including cerebral meningioma which was removed in 2011, diabetes, cerebrovascular disease, longstanding anxiety and depression, renal failure and chronic obstructive airways disease. She was a long term resident at Pine Trees Care home, Tuffley, Gloucester, having moved there in 2011. She had two admissions to hospital in August and October 2014 with chest related problems. She was able to mobilise using a walking aid and / or with assistance from carers. However her mobility was gradually deteriorating. On the 24th December she was on antibiotics for a chest infection. During the day on the 27th December 2014 she appeared her usual self. During the morning on Sunday 28th December Betty was complaining that she had some pain and that a member of staff had hurt her. She made several members of staff aware of that fact. No medical review from a doctor was sought. Police were not informed. Emergency services were requested at approximately 21.45 hours. Paramedics arrived at 1.15am on the 29th December, and transferred Betty to hospital. She was admitted to hospital in the early hours of the morning on the 29th December 2014 having sustained injuries to her legs and chest, including multiple fractures. These injuries were caused by a significant incident probably occurring during the morning of the 28th December 2014. The medical cause of these injuries whether due to a fall/ how she was handled by a carer remains unclear. It is more probable than not that a member of staff was aware that Betty had sustained a significant injury, and did not report that fact. Police were informed by hospital staff in the Accident and Emergency Department. After admission to hospital she subsequently deteriorated with clinical evidence of respiratory failure and sepsis. Her clinical deterioration was related to her underlying injuries. Her medical history made her more vulnerable to such a decline. She died at 06.43 hours on the 31st December 2014.

(1) No member of staff reported the injury that Betty sustained, and
(2) No member of staff escalated Betty’s allegations that a member of staff had hurt her until approximately 12 hours after she first made the allegation.