A 93-year-old woman died after medics failed to spot a growing pressure sore for nearly two months after she was scalded by boiling water from a kettle, a coroner ruled.
Great-grandmother Freda Owens suffered horrific burns to her backside after being sat on a commode of water heated to 110 degrees in an attempt by her carer to treat a stomach complaint.
Her painful injuries had forced her to lie on her side and this had caused a deep tissue pressure sore close to her left hip bone to worsen.
Coroner Alan Wilson heard that the wound was not spotted by a district nurse, who examined Mrs Owens after the incident at The Croft House Rest Home in Freckleton, on November 2, 2012.
As the former cashier’s condition deteriorated she was admitted to Royal Preston Hospital on November 23.
But the sore contunued to go unnoticed until Christmas Eve – nearly two months after the incident.
She died in the hospital on January 3, 2013.
Coroner Alan Wilson concluded that two factors contributed to Mrs Owens’ death – the horrific burns she suffered as a result of the commode and the delay in treatment this caused for her pressure sore.
He said staff had failed to spot the sore because her burns were so severe she found it painful when moved.
Speaking after the Blackpool inquest, Mrs Owens’ family slammed the “shocking standard of care” she received.
They said: “The death of Freda was not just avoidable or preventable but needless and unnecessary.
“There can be no doubt that the sub-optimum care, together with the scald incident itself, resulted in unnecessary, needless and prolonged suffering.
“The verdict has been a long time coming but unfortunately it has all been too little, too late. Freda has died. Nothing can bring her back or undo the harm she suffered.
“It is with regret that the ripple effects of this has far reaching consequences and the pain and suffering continues for those that Freda left behind.”
Daughter Susan Tate, 69, and granddaughter Kerry Esgate, 39, said Mrs Owens, a great-grandmother-of-four, had been living independently but suffered a fall three years ago.
They said she never returned home after injuring her wrist and was placed straight into the care home by the hospital.
Micaila Williams, representing the family, told the court that Mrs Owens developed a pressure sore in October 2012, which “wasn’t managed properly”.
Referring to the burns she suffered from the commode, she said: “No practice was in place to allow that procedure to take place.
“It was inherently risky and dangerous and the water wasn’t tested and the pressure sore was under-assessed by district nurses.
“Due to the burns, she was unable to move properly and risk of further pressure sores heightened.
“The district nurse wasn’t made aware and there was a lack of communication that clearly led to difficulties moving forward.”
Mr Wilson said: “Freda was placed in a commode in her room at her care home in the hope steam would ease constipation.
“This unintentionally resulted in burns and scalds.
“On November 21, she was examined but that didn’t include assessment of her left hip area and she deteriorated.
“On November 23, she was hospitalised and it was not until December 24 that the injury to her left hip was recognised as a pressure sore.
“There was a delay in treatment which could have affected the outcome.
“I don’t find failings at the care home as a whole, aside from the action of the individual carer who utilised the commode.”
Mr Wilson returned a narrative verdict and accepted evidence given by Dr Alison Armer, a pathologist at the Royal Preston Hospital, who reported the cause of death as being bronchial pneumonia due to necrotic, chronic pressure ulcer to the left hip and burns or scalds to the buttock.
Police spoke to the carer but it was decided she should not be prosecuted.