Dingwall care home resident’s death “avoidable”

THERE was “every chance” an elderly Dingwall care home resident would have survived her infected bed sores if reasonable steps had been taken, according to a sheriff.

Jamesina MacKenzie, a resident at Wyvis House Care Home, died on May 31 2009 at Invergordon County Community Hospital at the age of 87 from multiple pressure sores she developed while at the home.

The circumstances of her death were examined during a lengthy fatal accident inquiry held at Dingwall Sheriff Court before Sheriff Alasdair MacFadyen.

In his findings, the sheriff said that in the midst of misunderstandings and inadequate supervision of her care, Miss Mackenzie’s deterioration was not properly recognised by the care home or the Dingwall medical group until it was too late.

The sheriff said: “There is no doubt that Miss MacKenzie’s relatives will feel that she was badly let down in the last few weeks of her life. She entrusted her care to a care home and the professional services of her general practitioners and Highland Health Board. Highland Health Board, in the person of Miss Law, the vascular nurse specialist, fulfilled its responsibility and, in my view, is beyond criticism. Otherwise, in the midst of apparent misunderstandings and inadequate management and supervision of her care, her deterioration was not properly recognised or addressed by the care home or the general practice until it was too late to prevent her death as a result of the progression of the pressure ulcers.

“The knowledge that this combination of circumstances was allowed to occur will, I hope, enable care homes and general medical practices, to identify similar factors at an earlier stage and allow measures to be taken to prevent the recurrence of such a situation being allowed to develop.”

The sheriff found the death of the retired vet might have been avoided if a complete and accurate recording of the treatment of the wounds had been taken and if proper supervision by the home management had ensured the care was being given and documented.

He also said it would have been a reasonable precaution for a GP to ask to see daily plan notes and for GPs to have examined Miss MacKenzie on a regular basis.

He said: “Since such examination would have made the deterioration in the condition obvious and would in all likelihood have led to a decision being made to admit her to hospital for treatment which might have prevented the death.”

The sheriff said the circumstances of inadequate care and recording of the level of care given to Miss MacKenzie occurred at the time of a change of ownership of Wyvis House, where the obligation on the new owners and management was to maintain or improve the quality of care to individuals.

The sheriff said that against the background of Miss MacKenzie suffering the progression of a significant illness in the form of pressure ulcers, while living in a care home setting, it was appropriate in the future for the Social Care and Social Work Inspectorate Scotland to have regard to the level of medical and nursing expertise available to the care home and to include in their inspection regime an audit of the necessary record keeping.

The FAI findings stated that on May 8 it was possible for Miss MacKenzie to recover the ill-effects of the pressure sores, but by May 22 they were no longer survivable.

“During the time that Miss MacKenzie was a resident in Wyvis House she was powerless to do anything herself about the pressure sores,” said the sheriff.

“She was reliant for her care and the treatment of the pressure sores on the management and staff of Wyvis House during that period.

“Had the treatment regime recommended by the vascular nurse specialist, Delia Law, been complied with after 8 May 2009, there was every chance that Miss MacKenzie would have survived said pressure sores, that they would have recovered and that they would not have led to her death.

“However, it cannot be said with any certainty, even on the balance of probabilities, that that regime was complied with by the nursing staff.”

However, the sheriff added he did not doubt the good intentions of the nursing staff charged with her care.