Joan RICHARDSON · Prevention of Future Deaths report

On 29/06/2020 I concluded an investigation and Inquest touching upon the death of Joan RICHARDSON 07/08/1921- 18/05/2020. Joan died in Whiston Hospital Merseyside. The conclusion of the inquest was that:

Joan Richardson sadly died on 18/05/2020 at Whiston Hospital Merseyside, Joan was a frail 98-year-old lady who had lived alone in supported accommodation. In April 2020 Joan’s condition started to deteriorate, she was requiring more support with personal care, she was not eating enough for her needs and she was also showing signs of confusion.

Joan had a DNAR in place and she was taken to hospital on 04/05/2020 due to concerns from her carers that she was becoming less responsive/her condition was deteriorating. On admission to hospital Joan was diagnosed with pneumonia, she had deep tissue wounds (grade 4) to her sacrum that were not infected, and she was also found to have a fractured neck of femur.

On 07/05/2020 when Joan was clinically as stable as possible, she underwent surgery to her hip. Following surgery notwithstanding all appropriate care and treatment in hospital Joan’s condition continued to deteriorate culminating in her death.

In summary/conclusion, on 23/04/2020 the warden from the accommodation complex called an ambulance such was her concern about Joan’s deterioration, however, the ambulance service determined Joan did not need to go to hospital but she did need help with personal care. The warden had shown great compassion towards Joan.
On 24/04/2020 Joan was assessed as needing home care by the local authority (Adult Social Care) in a timely manner and care was provided until a care provider was able to
take over her care on 29/04/2020, 4 times per day.

Joan was not seen up out of her bed after the bedtime visit on 30/04/2020 when she was noted by carer’s to have been in the kitchen. After that Joan remained in bed and she presented as being unwell and she showed signs of being in pain when the provision of personal care was attempted which she generally refused. Carers were unable to change her regularly or to provide pressure area care or relief as was necessary for Joan who was frail, elderly, immobile and incontinent.

Following her admission to hospital Joan received all appropriate care and treatment, however when at home, following the appointment of care providers some care related documentation/care plan was not completed in a timely manner by the care provider in the four days that Joan was under their care as it should have been and the deterioration in Joan’s poor condition, the fact that she no longer got up from her bed, refusal to eat and have assistance with her care needs and stated that she did not feel well should have been escalated as being of significant concern and to have enabled additional/appropriate action to be taken but it was not and Joan did not receive care to her pressure areas, noting she was admitted to hospital with a grade 4 pressure ulcer to her sacrum.

A carer did seek advice from a senior member of staff who visited Joan and subsequently an ambulance was called during the early morning visit 04/05/2020 when Joan was admitted to hospital.

Joan RICHARDSON had lived independently in sheltered housing. Her health began to deteriorate in April 2022 and on 29ᵗʰ April 2020 Joan began to receive home care four times per day by a care provider known as Litch care. The sole Proprietor being ████████ also known as ████████.

Joan was admitted to hospital on 4ᵗʰ May 2020.

(brief summary of matters of concern)
Joan had only started to receive care at home four times per day from lunch time of 29/04/2020, however when Joan failed to get up from her bed, refused food and fluids, complained of pain and generally started to deteriorate;-

1. The matter of Joan’s general deterioration was not escalated as it should have been to her GP/District Nurse/Commissioning Social Services etc.
2. When Joan complained of pain -the matter was not escalated as it should have been.
3. There was no comprehensive plan of care, risk assessment, pressure area care plan/risk assessment, falls assessment and care plan put in place following assessment by Litch care services. The manager/proprietor ████████ Registered manager informed the court they were still in the process of doing risk assessment/s etc because Joan was only receiving their care for 4.5 days before she was admitted to hospital.
4. Joan was admitted to hospital with Grade 4 pressure ulcers/tissue injuries to her sacrum, but because Joan had refused much of the personal care offered to her and she had remained largely immobile in bed the pressure sores/tissue injuries were not documented, assessed or managed as they should have been nor was the tissue viability nurse, GP, District nurse or social care team informed to enable them to commence/prescribe appropriate treatment.
5. There were no records/daily log making any mention of skin integrity/breakdown even though Joan was in bed, frail, immobile and incontinent in addition to which because Joan was refusing care her incontinence pad were not being changed regularly.
6. Training/education, support & supervision of care staff including the provision of clear escalation procedures was inadequate. Noting care staff attended upon Joan regularly as required.