Thomas Allan Ratchford · Prevention of Future Deaths report

On the 28 November 2017 I commenced an investigation into the death of Thomas Allan Ratchford. The inquest concluded on 26 April 2018. The medical cause of death was

1a) Sepsis

1b) Osteomyelitis

1c) Infected sacral pressure sore

2) Type 2 Diabetes, Chronic Obstructive Pulmonary Disease, Parkinsons Disease Dementia and Immobility

I recorded the following Narrative Conclusion:

“Against a background of long-term immobility and a number of co-morbidities, the Deceased died as a result of an inju sustained during respite care and contributed to by inappropriate use of a hoist for pressure relief.”

Mr Ratchford had a number of medical conditions including Parkinsons Disease Dementia which meant that he had been immobile for 6 years before his death. For most of that time he had been cared for at home by his wife with the support of carers and District Nurses. On 4 October 2017, he was admitted to Marland Court Residential Home for a period of respite care. During the admission, he developed a deep tissue injury which extended from his sacrum, around his rectal area, to his inner thighs. The carers at Marland Court Residential had been using the hoist to elevate Mr Ratchford from his seat in the mistaken belief that this would provide pressure relief. It is more likely than not that this practice contributed to his death.

The use of the hoist to provide pressure relief is not one that was either recognised or recommended by the Tissue Viability Nurse who gave evidence at the inquest. It was a practice that had been adopted by the carers at Marland Court Residential Home without obtaining advice from either the hoist manufacturers or the District Nurses. Had advice been taken, the carers would have been informed that it was not recommended. The matter of concern that neither the Home Manager or the carers had received sufficient training in moving and handling and pressure relief.