An elderly care home resident died with bed sores so severe that they had rotted to the bone.
Jamesina MacKenzie was being treated at the facility in the Highlands when her health deteriorated.
A fatal accident inquiry into the 87-year-old’s death found it could have been avoided if staff at Wyvis House in Dingwall had observed and monitored the pressure sores throughout her time there.
Retired vet Miss MacKenzie was initially refused hospital treatment, but when she was moved to Invergordon County Community Hospital, medical practitioners said her bed sores were among the worst they had ever seen.
The care home, in the town’s Station Road, was threatened with closure after the Care Commission ruled its standard of care was "unacceptable".
During the inquiry heard at Dingwall Sheriff Court last November, Miss MacKenzie’s nephew Murdoch MacDonald described his aunt as "lucid, very sharp and mobile" before she was moved to the care home.
He also told the inquiry that Miss MacKenzie had complained to her family about not getting breakfast and was being left in bed until midday.
During the evidence hearings, Invergordon health staff revealed that Miss MacKenzie’s bed sores had rotted her flesh so extensively that it would have exposed her hip bone. RDS Healthcare Ltd, which owned the care home, admitted during the inquiry that it had committed failings in its handling of the pensioner.
Ms Mackenzie, from Torridon, in Wester Ross, died in hospital on May 31, 2009. Staff at Invergordon raised concerns about her medical condition with police, which resulted in the fatal accident inquiry being heard.
Sheriff Alasdair Lorne MacFadyen found that there were a number of "reasonable precautions" that might have prevented Miss MacKenzie’s death if they had been taken.
He stated if staff at Wyvis House had carried out "complete and accurate recording" from when the pressure sores were first recorded in April, more than a month before Miss MacKenzie’s death, she may not have died.
On Tuesday, Sheriff MacFadyen found that had "proper leadership and supervision by the management" at the home been in place, the death may have been avoided, while he also stated that relatives of many residents had voiced concerns about changes to staffing at the facility following RDS’s takeover of it in March 2009.
He also highlighted the role of GP and a specialist nurse from Raigmore Hospital in Inverness in failing to inspect Miss MacKenzie’s pressure sores on a regular basis.
The sheriff stated had the deterioration of her health and the worsening of the wounds been recorded and monitored properly, it would have "all likelihood have led to a decision being made to admit her to hospital for treatment which might have prevented the death".
In his findings, the sheriff noted that pressure sore specialist Delia Law, based at Raigmore, had attended the home to examine Miss MacKenzie in response to a request from staff on May 8, 2009.
She recommended a course of treatment for the retired vet, and "left the staff at Wyvis House in no doubt that if Miss MacKenzie's condition did not improve, they should contact the General Practitioners or medical staff at Raigmore Hospital, Inverness."
Sheriff MacFadyen noted that it was "not possible" to say if this treatment plan had been followed at the care home, while Miss Law went off on annual leave and had other duties to attend to following her visit.
Between that visit and May 22, when Miss Law visited the home after returning from leave, the care home attempted to get GP Dr Lindsey Ross, of Dingwall, to visit Miss MacKenzie to check-up on her condition. But the doctor refused, because she wrongly believed that the resident was being treated by the specialist nurse during that time.
When she returned from holiday, Miss Law inspected Miss MacKenzie’s sores and found that she the pelvis bone had become exposed since the last inspection, while the pensioner’s health had "deteriorated considerably". She also noted that the resident had become septic before Miss MacKenzie was admitted to hospital that day.
In his findings, the sheriff stated: "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."
- Nurse reported care home over concerns about patient treatment
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