Bed-sores death is blamed on care home

THERE was “every chance” that the death of an elderly care home resident who developed pressure sores could have been avoided if a treatment plan had been properly followed, a sheriff has ruled.

Jamesina MacKenzie, 86, was found to have the sores while resident at Wyvis House care home in Dingwall, in April 2009. The retired vet died in hospital on 31 May, 2009, after developing blood poisoning.

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

In his determination, he said her death came amid “apparent misunderstandings and inadequate management and supervision of her care”.

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

The fatal accident inquiry 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 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 said if staff at Wyvis House had carried out “complete and accurate recording” from when the pressure sores were first recorded in April, Miss MacKenzie might not have died. He said the death might also have been avoided had “proper leadership and supervision by the management” at the home been in place.

Sheriff MacFadyen stated that relatives of many residents had voiced concerns about changes to staffing at the home.

He said that had the deterioration of Miss MacKenzie’s health and the worsening of the wounds been recorded and monitored properly, it would in “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, he noted that pressure sore specialist Delia Law, based at Raigmore, had attended the home to examine Miss MacKenzie in response to a staff request on 8 May, 2009.

She recommended a course of treatment and “left the staff at Wyvis House in no doubt that if Miss MacKenzie’s condition did not improve, they should contact the GP or medical staff at Raigmore Hospital.”

When she returned from holiday, Miss Law inspected Miss MacKenzie’s sores and found that her pelvic bone had become exposed since the last inspection, while the pensioner’s health had “deteriorated considerably”.

Miss MacKenzie’s nephew, Murdoch MacDonald, from Evanton, Easter Ross, had told the court his aunt had worked abroad and in London and Perth, before returning to the Highlands to be closer to her family.

He described her as “lucid, very sharp and mobile” before moving to the care home.

A spokesman for the Dingwall Medical Group said: “We strive to provide the best possible care at all times and if lessons require to be learned or changes to practice made then we will endeavour to address the issues raised.”

No-one from the care home was available to comment.