NHS chiefs apologise after 90-year-old man dies from untreated sores
Coroner calls for improvements to prevent similar deaths
14 June, 2019 — By Tom Foot
University College Hospital
NHS chiefs have apologised after a frail and bed-bound 90-year-old man died when pressure sores and ulcers in his knee were left untreated.
Central North West London (CNWL) NHS Trust, which employs Camden’s NHS carers, said it had “deep regret” over the death of John Pearce, who lived in Mackeson Road, Gospel Oak.
A small wound had been allowed to develop into an infected 7cm-deep ulcer that left “tendons and bone exposed”. District nursing teams and carers – who had wrongly reduced home visits before his death in September last year – did not refer him to the emergency services until it was too late.
St Pancras assistant coroner Edwin Buckett said “the trigger” for his death was “ulceration/ pressure sores” which had worsened significantly over two months after he was discharged from University College Hospital.
A Prevention of Future Deaths report filed by the coroner said: “No one appeared to recognise the severity of the injury and the fact that tendons and bone were exposed. It is clear to me that he should have been admitted to hospital far earlier and that earlier treatment of his knee injury may have prevented his death.”
The report said that in April, Mr Pearce, who could not get out of bed, injured his knee after it “somehow came into contact with a metal safe in his property”.
He was taken to UCH in July when doctors discharged him without any serious concerns. But in August, nurses reported the wound was “increasing in size” and that the ulceration in his knee “was really bad”. A series of photographs and measurements were taken of what was recorded as “a very severe knee injury” that had become “necrotic” – when surrounding cells decay.
The report said that, despite a decision being taken to increase visits, there were “insufficient attendances” by the district nursing team. When he was admitted to UCH on September 15, the knee ulcer was diagnosed as grade 4, the most severe possible. Mr Buckett’s report said that Mr Pearce had not wanted to go back to hospital, but “too much emphasis was placed on his own view”.
CNWL said that it was now training staff in how to manage patients who “declined” care.
The coroner said CNWL should have clearer protocols for when to make emergency referrals, adding: “In my opinion, there is a risk that future deaths will occur unless action is taken.”
A CNWL statement said: “This was a very sad event. We deeply regret the death of Mr Pearce and apologise for the failings identified. We have told the coroner about changes we have made to learn from this. The understanding of trust policy and procedures for the team involved in the care of Mr Pearce has been reinforced with education sessions and we have highlighted the learning from this sad case to all trust staff. ”
It added: “Regrettably some of the care that was offered to Mr Pearce was declined. Our education sessions have stressed that any decision to reduce the level of visits should only be taken after discussing the potential consequences and risks in detail with the patient and those involved in the patient’s care, and clearly documented. A training session has been held about assessing mental capacity at home.” “We appreciate this offers little consolation in this specific event but other patients will benefit from this learning.”