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Investigation and inquest
On 5th August 2013 I commenced an investigation into the death of MARGARET CONNOR, aged 91 YEARS. The investigation concluded at the end of the inquest on 8th May 2014. The conclusion of the inquest was medical cause of death: 1a) Bronchopneumonia 1b) Dementia Part II Periprosthetic fracture of right tibia, and narrative conclusion “Natural causes contributed to by a fracture to the right tibia which probably occurred on 3.7.2013 and which went undetected until admitted to hospital and an x ray was performed on 12.7.2013”
Circumstances of the death
Mrs Connor was a resident in Heathers Nursing home. On 3.7.2013 she was seen by a carer in a wheelchair where the footplate was misplaced to one side, although the evidence was that Mrs Connor's leg and foot were not in an abnormal position. There was further evidence that the footplates are sometimes loose and not fitted properly (as in this instance), do not match and are not the right footplates for a particular wheelchair. It was accepted on behalf of the Nursing Home this is when Mrs Connor probably suffered a fracture to her right leg. During the course of the next few days Mrs Connor was noticed to have a lump to her knee, pain, swelling and increased bruising. Doctors were called out but were told there had been “no trauma” to her right leg. Mrs Connor was admitted to Hospital by a GP on 12.7.2013. An x ray was carried out on 13.7.2013 which showed a fracture. Mrs Connor's condition continued to deteriorate and she died on 2.8.13. The Post Mortem Report comments "The debility caused by the recent fracture is likely to have contributed to the death".
Coroner’s concerns
(1) Insufficient procedures are in place to check wheelchairs before use. Carers collect a wheelchair from an alcove and are required to check over before it is used. It would appear this is not always being done.
(2) Wheelchairs are left in the alcove ready for use without footplates, loose footplates and mismatched footplates.
(3) There are insufficient/no independent checks being carried out on wheelchairs on their return to the alcove. They are only referred to “the maintenance man” if there is something noted to be wrong with them.
(3) The attending Doctors were being told there had been “no trauma” to Mrs Connor's leg, despite concerns being raised by her family that her foot/leg had been injured on the wheelchair and despite the faulty plate having been seen by staff.
Information checked against the published report and official responses