Dorothy McDermott · Prevention of Future Deaths report

On the 10th February 2015 I commenced an investigation into the death of Dorothy McDermott for whom the cause of death was confirmed at Inquest as being that of 1a) Septicaemia, 1b)Decubitus Ulcer / Bed Sore with Hypertension and Urinary Tract Infection, whilst not causative of death, being contributory factors under 2.

At an Inquest convened on the 2nd July 2015 the following conclusion was made –

‘Against a background of increasing immobility and susceptibility to urinary tract infections, Dorothy McDermott was at high risk of developing pressure sores. On the 17th January 2015, having fallen three times that day, she was admitted from home to emergency respite care where she remained until the 26th January. She was not examined when attended upon by a GP on the 20th January and subsequently opportunities to examine her sacrum were missed by reason of inadequate training of care staff. The evidence does not show when the Grade 4 pressure sore developed but more likely than not, it would be over a number of days prior to the 26th January on which date a visiting District Nurse was alerted to concerns raised by care staff by which time Mrs McDermott was already in extremis. She was admitted to Fairfield General Hospital where she died during the early hours of the 27th January 2015’.

As above

Dorothy McDermott was 80 years old. She had been housebound for 2½ years. She had been diagnosed with a urinary tract infection and was confused. On the 17th January 2015, she had fallen three times whilst at home. Paramedics advised a rapid response but they finished at 5.30pm. Mrs McDermott required a place of safety. Following discussions between the Local Authority’s emergency duty team and the out of hours service for the district nursing team, emergency respite care was arranged at the Littleborough Care Home to which Mrs McDermott was conveyed during the early hours of the 18th January. It was envisaged that Mrs McDermott would be reassessed on the 19th January. The Littleborough Care Home offered residential but not nursing care. Care staff at the home were not trained in either the examination for or care of pressure sores. That placement was inappropriate. The rationale for that decision one of availability with the facility of a ground floor bedroom which had been newly decorated.

Whilst appreciating that the decision to procure respite care was made ‘out of hours’ the overriding concern given the extent of Mrs McDermott’s vulnerability should have been to obtain a suitable placement which guaranteed a place of safety. Whilst not wishing to be prescriptive, formal Guidance is required to as to ensure that vulnerable individuals are appropriately placed by the Agencies involved.