Woman with dementia died after developing bedsores at nursing home, inquest hears

A woman with dementia was neglected by nursing home staff and left to develop infected bedsores in the months leading up to her death, an inquest has heard.

June Hamer, 71, died weeks after she was examined by a doctor on her family’s instruction after they became concerned about the lack of care given to her at Brithdir Nursing Home.

An inquest in Newport, Gwent, is hearing evidence into the deaths of seven residents of the care home in New Tredegar between 2003 and 2005, some of whom suffered from dehydration, malnourishment, and pressure sores.

On Thursday, a statement from Mrs Hamer’s husband, Ronald Hamer, described the neglect his wife received after she moved there in October 2003, after her dementia meant he could no longer care for her at home.

Mr Hamer, who gave the statement during an earlier police investigation, said: “I felt that if I was not there, no one would make sure she had been fed or received a sufficient quantity of fluid.

“I found that if she needed changing, I had to ask staff to attend to her. They seemed to be more interested in smoking and chatting at the end of the corridor rather than attending to the needs of the residents.”

Mr Hamer said he noticed his wife’s health and physique deteriorate by July 2004, and that by then her mouth had swollen up and blistered as a reaction to being given penicillin, which her care notes stated she was allergic to.

At the beginning of that August he said he noticed a bedsore on his wife’s back had become infected, and had to arrange for a doctor to see her immediately after a care home nurse told him “she could not” do so herself.

Dr Nada El-Manhani, a GP at a surgery where Mr Hamer’s daughter-in-law worked as an office manager, examined Mrs Hamer at the nursing home and concluded the large, infected ulcers were contributing to her ill health.

The GP said in a statement the sores were severe enough to cause septicaemia and arranged for her to immediately go to the Prince Charles Hospital in Merthyr Tydfil.

Mrs Hamer remained at the hospital for the next few weeks until she died on August 27, with experts later concluding the bedsores had likely contributed to her death along with bronchopneumonia and dementia.

Mrs Hamer’s daughter, Tracy Allen, said she found carers at the home “hopeless”, and said how during her mother’s stay she was forced to have most of her teeth removed due to infections in her mouth and gums.

One former carer who worked there during Mrs Hamer’s stay, June Smith, said she didn’t receive any training despite several requests to then-manager Peter Smith.

Staff were never told to clean residents’ teeth, nor were they given “slide sheets” which are used to reposition immobile patients in their beds if they suffered from bedsores.

“I was never informed of specific ways to turn residents, or even to turn residents through the night. In fact, I would say I was specifically instructed not to disturb patients while they were sleeping,” she said.

The inquest heard the nursing home failed to record whether daily activities and assessments developed for Mrs Hamer’s individual care plan were ever carried out, despite being assessed as needing a “high level of nursing care”.

Daphne Richards, who initially joined Brithdir as a nurse before becoming its acting manager in January 2004, admitted the lack of completed paperwork for Mrs Hamer was “unacceptable”.

Appearing at the inquest via video link, she said she didn’t know how to treat Mrs Hamer’s bedsores, and that she had trusted her staff’s “integrity” to follow hers and other residents’ care plans.

Mrs Richards said she was often short staffed, adding: “Working as a manager was not properly working as a manager, because I wasn’t coping half the time.”

Asked by coroner Geraint Williams whether she believed she was partly responsible for the development of Mrs Hamer’s pressure ulcer, Mrs Richards said: “I think we all bear responsibility. All the qualified nurses.”

Mrs Richards was struck off the nursing register in 2015 following Gwent Police’s Operation Jasmine, which was launched in 2005 and uncovered failings at a number of care homes in the area.

Brithdir was closed in 2006, with its owner, Dr Prana Das, suffering a brain injury in 2012 which meant he never stood trial for alleged failings in care, before he died in January last year aged 73.

The inquest, set to last until March, will also look at the deaths of former Brithdir residents Stanley Bradford, 76, Edith Evans, 85, Evelyn Jones, 87, and William Hickman, 71.

A hearing into the death of a seventh resident, Matthew Higgins, 86, will be held following the conclusion of the other six.

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