Dingwall care home and GP criticized over woman’s death

Synopsis: An 87 year old woman’s death was due to preventable decubitus ulcers, or pressure sores. The flesh had rotted away down to the bone because of the bed sores, according to the police report. The nursing home will be held liable for their negligence.

“A care home and local GP practice have been criticised by a sheriff following an 87-year-old woman’s death caused by her infected bed sores.

Retired vet Jamesina Mackenzie, who had been a staying at Wyvis House in Dingwall, died at Invergordon’s county hospital in May 2009.

Nursing staff at the hospital alerted police who investigated the care home.

Sheriff Alistair MacFadyen said Ms Mackenzie’s condition was not properly addressed until it was too late.

A fatal accident inquiry (FAI) last year heard that Ms Mackenzie had a bed sore with flesh rotted away down to a bone.

In his newly-published determination, Sheriff MacFadyen said her death came amid “apparent misunderstandings and inadequate management and supervision of her care”.

However, he said later efforts to help Ms Mackenzie by NHS Highland and a specialist nurse were “beyond criticism”.

The FAI heard that she had been in the care of staff at Wyvis House and GPs at Dingwall Medical Group.

Sheriff MacFadyen 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.”

He went on: “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.”

‘Femoral cap’
During the FAI, consultant pathologist Dr Rosyln Rankin said the sores were avoidable and, if treated earlier, Ms Mackenzie could have lived “for many more years”.

Dr Rankin went on to tell the FAI: “One ulcer had gone through to the bone and you could see the femoral cap.

“When this wound was being dressed, you would have been able to see the hip joint working.”

The inquiry at Dingwall Sheriff Court also heard from Ms Mackenzie’s nephew Murdoch MacDonald, from Evanton, Easter Ross.

He said his aunt had worked abroad before later moving to London, then Perth, before moving to the Highlands to be closer to her family.

Following her death, Mr MacDonald said he wrote to the Care Commission about the care home.”

Original story from http://www.bbc.co.uk/news/uk-scotland-highlands-islands-18687758

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