Blackpool’s district nursing team has been branded ‘unfit for service’ after failing a dying Cleveleys woman.
Coroner Dr James Adeley became so concerned at the treatment of dementia patient Dorothy Imisson he has demanded health bosses take action to prevent further deaths.
He has also reported supervisor Catherine MaCauley to the Nursing and Midwifery Council (NMC) after accusing her of ‘smiling and chuckling’ her way through the 82-year-old great-grandmother’s inquest.
Mrs Imisson died from a stroke in 2014, but bed sores she developed after district nurses failed to tell care assistants how to prevent them were found to have contributed to her death, Dr Adeley ruled.
Blackpool Victoria Hospitals NHS Foundation Trust has now apologised and said they are taking the matter seriously, though it refused to say what punishment Ms MaCauley faced.
Mrs Imisson’s heartbroken daughter Julie Creasey, 58, said: “My mum was supposed to be in the best possible hands.”
My mum was supposed to be in the best possible hands
The inquest, held at Preston Coroner’s Court, heard Mrs Imisson had been moved to Morvern Care Centre, on the Prom in Cleveleys, because of her increasing dementia.
Staff at the care home, which does not employ qualified nurses, sought medical advice when her condition began to worsen.
She was first seen by district nurses on June 2, 2014 after being diagnosed with deep-vein thrombosis (DVT), and there were several follow up visits, the inquest heard.
The inquest heard that, despite one of the nurses not fully completing assessment forms, Mrs Imisson was classed as being at ‘very high risk’ of developing pressure sores.
Even though the nurses knew a care plan should have been developed and documented, none was, the court was told.
“The district nursing service was aware Dorothy Imisson had fairly rapidly deteriorating dementia, was immobile, had poor nutrition, poor hydration, and was doubly incontinent, all of which are significant risk factors for the development of pressure sores,” Dr Adeley said.
“There is no indications in records that any information was given to the home, despite the fact the district nursing service were aware Dorothy Imisson was at very high risk of developing such skin damage.
“When these issues were put to Catherine MaCauley, she said she was aware of the guidance on the requirements for record-keeping and in the absence of any records confirming an action, she would accept the general rule that ‘if it isn’t documented it wasn’t done’.
“Her explanation on behalf of the district nursing service was that they ‘didn’t have time to write records’, and accepted this compromised patient care, communication of care and continuity of care.”
He continued: “Of particular concern to the court was that Catherine MaCauley smiled and chuckled her way through the evidence and it did not appear to concern her that the nursing service were neither complying with professional mandatory requirements on record keeping, nor communicating with those providing care, nor with guidelines on what she accepted was a core area of business, and that she had not drawn failures to the attention of the court either in her oral testimony or in her witness statement.
“Catherine MaCauley explained that all of their interactions with residential and care homes were verbal as they did not have time to do anything else.
“Judging by the subdued exclamations from the family on the front row this clearly was not what they were expecting and caused them considerable concern.”
Dr Adeley said he was confident staff at Morvern would have followed any care plan designed to prevent pressure sores from developing, and said they did not realise – due to the lack of care plan – a blister Mrs Imisson developed could indicate a developing sore.
And after learning the home, the nurses, and a Community Care Coordination Team all had their own care plan, he described the multiplicity as ‘inefficient, wasteful of clinicians’ time’, and said it ‘introduces confusion into patient care and results from a lack of coordination between the various health care agencies’.
“In any event, the one care domain in which Dorothy Imisson did not have a preventative care plan was that of pressure area care,” he said.
Mrs Imisson was admitted to Blackpool Victoria Hospital on June 16, 2014, after her condition worsened, and given between two and eight weeks to live.
The former machinist was moved to Cleveleys Nursing Home on July 5 and, after another short stay in hospital, died there five weeks later.
Dr Adeley said he accepted the findings of pathologist Dr Mark Sissons, who said the sores ‘moderately’ contributed to Mrs Imisson’s death, although he heard they may have happened eventually anyway.
He also listened to testimony from expert witness Victoria Peach, lead nurse for community nursing services at Leicestershire Partnership NHS Trust, who said there were ‘a number of missed opportunities’ to improve care.
Dr Adeley added: “In my view the tissue breakdown occurred earlier than would have been the case had appropriate care plans been in place and care delivered in accordance with these.
“The tissue breakdown was more severe than otherwise would have been the case and in my view, due to the systemic effect, shortened Dorothy Imisson’s life by a number of days, to say nothing of the additional pain and distress it would have caused her.
“I consider there was a failure to deliver the basic care to a person in a dependent position. However, I do not believe that had pressure area care planning been provided it would have prevented the death.”
Recording a narrative verdict, he concluded: “Dorothy Imisson died from a naturally occurring stroke caused by atrial fibrillation [a heart condition that causes an irregular and often abnormally fast heart rate].
“Her death was contributed to by an absence of pressure care planning by qualified staff, resulting in a premature development of severe skin ulceration, a shortening of life, and increased pain and suffering.
“In view of the approach taken by Catherine MaCauley to noncompliance of mandatory guidance I would normally allow the trust a window of opportunity to address these concerns. In this case however, I’m sufficiently concerned with the management of the district nursing service that I will issue on of my rare regulation 28 letters to the director of nursing at the trust, copied to the chief executive, medical director, and the Care Quality Commission (CQC) stating that, from the evidence I’ve heard, the care provided is unfit for service.
“In addition, Mrs MaCauley’s conduct in court and general disregard for the guidance while in a position of supervision causes me sufficient concern that I’m referring her to the NMC.”
The coroner has a legal power and duty to write a report following an inquest if there’s a risk of other deaths occurring in similar circumstances.
This is known as a report under regulation 28 – or a Preventing Future Deaths report – and is sent to people or organisations in a position to reduce that risk through action.
They must reply within 56 days to say what action they plan to take. Following the inquest, Mrs Imisson’s daughter Julie added: “We didn’t understand how she was able to get such awful pressure sores when she had two carers charged with looking after her.
“We feel we now have those answers and hope that, by highlighting the lack of pressure care planning and the conduct of the district nurse, lives will be saved.”
‘We’ve updated our policies’
Pauline Skeen, manager at Morvern Care Centre, said: “We have now updated our policies and procedures surrounding the prevention of pressure area sores. We are really sorry that this happened.”
And Rebecca Brown, medical negligence lawyer at Irwin Mitchell, which has launched legal proceedings against the trust, added: “Dorothy’s family is still picking up the pieces
after her death and is hoping
the issues highlighted by the coroner and his decision to contact the CQC, among others, regarding the district nursing service, mean others will not suffer as Dorothy did.”
‘We would like to apologise sincerely to the family of Dorothy’
A spokeswoman for Blackpool Teaching Hospitals NHS Foundation Trust said: “Chief executive Wendy Swift and director of nursing and quality Marie Thompson would like to apologise sincerely to the family of the late Mrs Dorothy Imisson and wish to reassure both her relatives and members of the public that the trust is taking this matter extremely seriously.
“In our response to the coroner we will be demonstrating the learning and improvements that have been put in place since the tragic events of 2014.
“A full investigation has been instigated and all necessary procedures have been followed.
“We will offer the opportunity to meet with the family to share the findings of the investigation on its completion.”
When asked about the behaviour of Catherine MaCauley, the trust declined to comment further.