Nurse’s tears during inquiry into death of care home resident
A MENTAL health nurse broke down in tears at a fatal accident inquiry into the death of a Dingwall care home resident when she was questioned about the care provided to the elderly woman.
Jacqueline Fraser worked at Wyvis House Care Home while eighty-six-year-old Jamesina Mackenzie was a resident there.
Miss Mackenzie died from infected bedsores in May 2009 after she was transferred from the home to hospital in Invergordon.
During questioning on the third day of the inquiry Niall Ramsay, solicitor for the home owners RDS Healthcare, asked Mrs Fraser why her name was the only one that appeared in Miss Mackenzie’s patient notes to record that dressings were changed.
Mrs Fraser said maybe other nurses were changing the dressings, but weren’t documenting it.
“They were short staffed at the time,” she said.
Asked if she ever found the dressings hadn’t been done, she said when she came back to work once she found they hadn’t been done.
Mr Ramsay said he was confused, “Are you saying they hadn’t done the work or hadn’t done the documentation.”
Mrs Fraser then said she believed the dressings had been done but not documented.
Asked by Mr Ramsay if a lack of resources had any bearing on the care provided, Mrs Fraser replied, “No I don’t think so. It was because we had a lack of staff.”
Mr Ramsay told Mrs Fraser she had given him two answers which were diametrically opposite.
Mrs Fraser said she was getting a bit confused. She was asked by Mr Ramsay if she wanted time to consider her answer. She broke down in tears and the hearing was briefly adjourned.
When she resumed her evidence she was asked by Mr Ramsay if she believed she and her colleagues had provided “suitable, adequate and appropriate care” for Miss Mackenzie.
” We did,” she replied.
Sheriff MacFadyen told Mrs Fraser it was his duty to get to the truth and it was her duty to tell the truth.
“Do you think you are doing that?” he said.
“It’s a long time ago, I’m doing my best,” she replied.
He asked Mrs Fraser if she ever reported staff failures in recording dressing changes. She said she did only once to manager Joyce Reiman.
Earlier that day a specialist nurse told the inquiry that she believed the death of an elderly woman could have been avoided had she been hospitalised and received appropriate treatment sooner.
Delia Law, a specialist vascular nurse with NHS Highland, was on holiday when a call to her was made by staff at Wyvis House about their concerns for Miss Mackenzie.
Miss Mackenzie died from an infection caused by pressure sores on May 31, 2009 in Invergordon’s County Hospital, nine days after she was admitted.
Ms Law, who first examined Miss Mackenzie on May 8, was on leave when her condition deteriorated a week later and nursing staff at Wyvis House put in a call to her. When they couldn’t contact Ms Law they contacted a local GP.
But Ms Law said doctors took the view that Miss Mackenzie was dying anyway and it was decided not to move her from Wyvis House.
Ms Law said when she examined Miss Mackenzie on May 8 she expected her to recover because the sores appeared to be healing.
But two weeks later, after being on leave, she said she did not recognise the patient because of the deterioration in her condition.
Ms Law said she didn’t believe the staff were trying to conceal anything from her but when she went to examine Miss Mackenzie on the May 22 she thought she had been taken to the wrong room because she didn’t recognise the patient.
“I could see she had lost a lot of weight, was very gaunt, very unwell and was quite distressed,” she said.
A sore on her hip had not been properly dressed and there was no dressing on another sore on her heel.
Ms Law told the inquiry on this visit she was greatly concerned by Miss Mackenzie’s general condition.
“Her teeth were dirty, her lips were cracked and dry. She had no dressing on her heel and her hip was not properly dressed,” she said.
Ms Law said Ms Mackenzie’s nappy was also sodden.
Ms Law said she believed if Miss Mackenzie had been admitted to hospital on May 15 and given fluids and antibiotics intravenously she may well have recovered.
“By the 15th it should have been considered to put her into hospital. I suspect it might have made a big difference whether she would have recovered or not,” she said.
“I find it surprising she was not admitted to hospital sooner.”
Asked by solicitor Niall Ramsay if it would surprise her that the decision was taken by doctors that “There was no point (putting her to hospital) because she was dying anyway.”
Ms Law replied, “It may have been they felt she could not recover but I don’t know that I would agree with that.”
Earlier this week the inquiry heard from consultant pathologist Rosalind Rankin that in most cases pressure sores were avoidable and she had known of only two cases where bed sores had caused death in a career spanning over thirty years.
“If her sores had been treated earlier, this lady could have lived for many more years,” said Ms Rankin.
The inquiry continues.